Assessment Questionnaire

Please complete the following questions to help with the assessment

  • Care Recipient Information

  • Insurance Information

  • Contact Information

  • Medical History

  • Please list previous hospitalization and serious illnesses in the past 5 years:

  • Mobility

  • List Medications

  • Please list all medication to which you’ve had allergic or adverse reactions.

  • Medication Administration

  • Medical Information

  • Meals & Feeding Instructions

  • Family Information/Social History

  • Activity

  • REVIEW OF ACTIVITIES OF DAILY LIVING (ADL)

  • Wash body/hair in tub, or shower, with or without adaptive equipment. If sponge bathes, gets basin, soap, and wash cloth independently
  • Gets clothes from closets/ drawers, puts on and takes off clothes, fastens closures, with or without adaptive equipment.
  • Ability to perform bladder functions
  • Ability to perform bowel functions
  • Getting to/ from “toilet room, “transferring to/ from toilet, cleansing self, rearranging clothes, with or without adaptive equipment
  • Ability to walk and move from one place to another inside or outside
  • Ability to move in and out of chair or bed with or without assistive equipment.
  • Ability to get food or nourishment into the body after it has been prepared and made available
  • REVIEW OF INSTRUMENTAL ACTIVITIES OF DAILY LIVING ( IADL)

  • REVIEW OF BEHAVIORAL MANAGEMENT

  • Thank you for completing this information. Please fax, email or bring with you to the initial consultation this questionnaire to help expedite and begin the process of creating a care plan that will benefit all parties and promote quality of life.

    Best regards,

    Kathy C. Faenzi, MA
    Clinical Gerontologist