This assessment will help us determine the appropriate care and services the senior will need. Please complete the form to the best of your knowledge; however, you may leave items blank that you are unsure of or would like to discuss further. Upon completion of the assessment you will be contacted by an Administrator who will help create a personal care plan that is monitored on a daily basis.

Alternatively, you may call us directly at (310) 422 – 5364.

General Information

Responsible Person's Name (required)

Relation to the Senior



Senior's Name




General Health Condition

Health (Describe overall health condition including and dietary limitations)

Physical Disabilities (Describe any physical limitations including vision, hearing or speech)

Mental Condition (Specify extent of any symptoms of confusion or forgetfulness. Also describe participation in social activities (i.e., active or withdrawn))

Health History (List currently prescribed medications and major illness, surgery, accidents; specify whether hospitalized and length of hospitalization in the last 5 years)

Social Factors (Describe likes and dislikes; interests and activities)

Bed Status

Is this person ambulatory or non-ambulatory? (Ambulatory means able to demonstrate the mental and physical ability to leave a building without assistance of a person or the use of a mechanical device. An ambulatory person must be able to do the following:

Describe the senior's current living status

Tuberculosis Information (Any history of Tuberculosis in applicant's family?)

Date of Test

Any recent exposure to anyone with tuberculosis? Action taken (if positive)

Functional Capabilities (Check all items below)

Active, requires no personal help of any kind - able to go up and down stairs easily

Active, but has difficulty climbing or descending stairs

Uses braces or crutch

Feeble or slow

Uses walker YesNo If Yes, can get in and out unassisted? YesNo

Services Needed (Check items and explain)
Help in transferring in and out of bed and dressing
Help with bathing, hair care, personal hygiene
Does client desire and is client capable of doing own personal laundry and other household tasks (specify)
Help with moving about the facility
Help with eating (need for adaptive devices or assistance from another person)
Special diet/observation of food intake
Toileting, including assistance equipment, or assistance of another person
Continence, bowel or bladder control. Are assistive devices such as a catheter required?
Help with medication
Needs special observation/night supervision (due to confusion, forgetfulness, wandering)
Help in managing own cash resources
Help in participating in activity programs
Special medical attention
Assistance in incidental health and medical care
Other "Serviced Needed" not identified above
Is there any additional information which would assist the facility in determining applicant's suitability for admission?
If Yes, please attach comments on separate sheet.

valerie@visualeyezstudio.comOnline Assessment