Assessment Form

About The Resident

Prospective Resident

Height

Weight

Current Residence*

Other (please write in)

Reason for Moving

About You

Contact Name

Address

Street Address City State ZIP Code

Relationship to Resident

Phone

Email

Medical

Medical Diagnosis

Financial

Funding Source

Other

Activities of Daily Living

Please fill out the following questionnaire to the best of your ability

Dressing: Upper Body

Dressing: Lower Body

Hygiene: Hands & Face

Hygiene: Hair, Teeth, Make-Up, Shaving

Hygiene: Using Toilet/Incontinence Issues

Hygiene: Bathing or Showering

Mobility: Getting in or out of Bed/Chair

Locomotion: Needs Help w/Chair or Walking

Dining: Set Up/Cutting Up Food

Dining: Eating and Self Feeding

Bed Mobility: Turning and Positioning in Bed

Uses Walker / Wheelchair / or Both

Bowel & Bladder Function

Bowel: Continence Needs

If incontinent, please indicate level of frequency*

Urinary: Continence Needs

Urinary: Continence Needs*

Does the applicant require a catheter?*

Yes
No

Mental & Cognitive Status:

Alert & Oriented (to time, place and person)

Yes
No

Memory Loss (short term)

Yes
No

Disoriented (to time, place and person)

Yes
No

Memory Loss (long term)

Yes
No

Depression

Yes
No

Wanders

Yes
No

If You Selected Yes to Wanders please choose one of the following:

Exit Seeking?

Yes
No

Any challenging behaviors? (This includes things like being disruptive, agitated or aggressive, abusive, demanding and/or requiring frequent staff intervention. Is the resident delusional or does h/she have hallucinations?)

Yes
No

Please describe the resident's emotional status, personality, and demeanor:*

Other Items:

Currently Taking Medication?

Yes
No

Please list medication and any comments*

Needs nursing or medical treatments

Yes
No

Needs daily pain management

Yes
No

Vital signs monitoring

Yes
No

Require Injections

Blood Glucose Monitoring

O2 Therapy

Needs Night Care