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State of California—Health and Human Services Agency Department of Healt
h Care Services
Genetically Handicapped Persons Program
GENETICALLY HANDICAPPED PERSONS PROGRAM/ CALIFORNIA CHILDREN’S SERVICES
ANNUAL HEMOPHILIA COMPREHENSIVE CENTER EVALUATION
SPECIAL CARE CENTER (SCC)
Name: Date of Annual:
Address: Phone #:
City/State/Zip: SCC Coordinator:
PERSONAL DATA
Client name: Date of Birth:
Address: Phone #:
City/State/Zip:
HEMOPHILIA PROFILE
Home Infusion Program?
Yes_____ No_______
If yes: Dosage:
Prophylactic Replacement Therapy?
Yes No ______ _______
If yes: factor name, if specified by prescribing MD:
Demand Replacement Therapy?
Yes No _____ _______
If yes: factor name, if specified by prescribing MD:
Target Bleeding Sites: Frequency of Bleeds:
MEDICAL HISTORY
Diagnoses: Allergies: Height: Weight(kg):
Hospitalizations/Surgeries:
Dental:
Other Medical Problems:
Current Medications:
Pertinent Labs:
Durable Medical Equipment(DME)/Home Health Agency (HHA):
Primary Care Physician (if known):
Other Health Care Providers:
DHCS 9054 (8/07)
