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

    Phone

    Email

    Senior's Name

    Age

    Gender

    Weight

    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 Also describe participation in social activities (i.e., active or withdrawn))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?)

    PositiveNegative

    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
    YesNo

    Active, but has difficulty climbing or descending stairs
    YesNo

    Uses braces or crutch
    YesNo

    Feeble or slow
    YesNo

    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.