Online Assessment

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 Also describe participation in social activities (i.e., active or withdrawn))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

Select OneOut of bed all dayIn bed all or most of the timeIn bed part of the time

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:

Select OneAmbulatoryNon-ambulatory

Describe the senior's current living status

Select OneAt home aloneAt home with familyNursing homeHospital

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

YesNoPositiveNegative

Date of Test

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

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