Assessment Questionnaire Please complete the following questions to help with the assessment Care Recipient InformationCare Recipient Name:*Street address:*City:*State:*Zip:*Years at this address:*Telephone #:*Email:* Date of Birth:* Age:*SS#:*Insurance InformationPrimary Medical Insurance:ID#:Pharmacy Insurance:ID#:Contact InformationSpouse Name:Marital Status:SingleMarriedDivorcedDomestic PartnerPrimary/ Emergency contact:Address:Telephone number:Email address: Durable Power of Attorney (Health):Durable Power of Attorney (Finance):Do you have a POLST (Physician Orders for Life- Sustaining Treatment:YesNoDo you have an Advanced Health Care Directive?:YesNoIf yes, upload copyPrimary Physician:Physician Address:Telephone:Fax:Last visit date: Reason:Dentist Name:Dental Insurance:Specialty Doctor:Specialty:Specialty Doctor:Specialty:Specialty Doctor:Specialty:Pharmacy:Phone:Medical HistoryHospitalization last 5 years:YesNoPlease list previous hospitalization and serious illnesses in the past 5 years:Date: Reason:Date: Reason:Date: Reason:Date: Reason:Use of Alcohol:YesNoPlease describe frequency and amount:Use of tobacco:YesNoPlease describe frequency and amount:Use of coffee:YesNoPlease describe frequency, type and amount:MobilityHave you had any problems with walking and/ or mobility in the past five years?YesNoDescribe gait and mobility:Are you currently using any medical appliances or assistive devices?YesNoType of appliances or devices:Recent Falls / Injuries?:Are you still driving?:YesNoWho provides transportation?:Medical diagnosis:Describe your health?:GoodFairPoorWhat medical problems are you currently having? Describe, if yes:List MedicationsAttach a list if available:Prescribed:Over the counter drugs: Please list all medication to which you’ve had allergic or adverse reactions. Describe the reaction:Medication AdministrationWhat is the system for distribution of medication? Please explain:Who administers medication?:SelfCaregiverFamily MemberWhat is their level of training? Please explain:How and where are medications stored? Please explain:Medical InformationGlaucoma, macular degeneration, blindness, blurred vision or cataracts:NoYesSeizures- include last date of seizure:NoYesHigh blood pressure or low blood pressure:NoYesStroke or transient ischemic attacks- Note any residuals:NoYesAngina, chest pain or heart conditions:NoYesCirculatory disorders including skin ulcers:NoYesDizziness, unsteadiness, imbalance, weakness or fainting:NoYesFalls, fractures:NoYesIf yes, last date: Arthritis, degenerative joint disease or joint replacement:NoYesOsteoporosis / compression fracture:NoYesDisorder of the blood or immune system:NoYesDiabetes or complications of diabetes:NoYesType I or Type II:Type IType INAInsulin injection:NoYesNACancer:NoYesAlzheimer’s disease, dementia, forgetfulness, confusion or memory loss:NoYesDepression, anxiety or any psychiatric condition:NoYesParkinson disease, tremors or other neurological conditions:NoYesKidney disease:NoYesCirrhosis of liver or liver disease:NoYesEmphysema, COPD, shortness of breath or oxygen use:NoYesAny other medical condition not previously notes?:NoYesMeals & Feeding InstructionsSpecial diets:Lo-SodiumDiabeticTexture::RegularCut-upMechanical SoftPureeSpecial Needs:Food dislikes:Food Allergies:Supplements:Family Information/Social HistorySpouse Name:Spouse Occupation:DPOA/Primary care provider:Children Names and Ages:ActivityHow would you rate the activity level on a scale 0-10?:012345678910Describe activities on a typical day:Do you participate in an exercise program?YesNoPlease describe type of program, frequency, and date of last activity:What are your interests / hobbies?:Do you own a pet?:YesNoType and nameWhat is / was primary occupation/ work history?:Special friends, groups, community service:REVIEW OF ACTIVITIES OF DAILY LIVING (ADL)BATHING:Requires no assistance or supervisionRequires cueing or some assistance in bathingRequires substantial assistanceUnable to perform any of the activity independentlyWash body/hair in tub, or shower, with or without adaptive equipment. If sponge bathes, gets basin, soap, and wash cloth independentlyWho assists?:Frequency:DRESSING:Requires no assistance or supervisionRequires cueing or some assistance in bathing (tying shoes, managing zippers)Requires substantial assistanceUnable to perform any of the activity independentlyGets clothes from closets/ drawers, puts on and takes off clothes, fastens closures, with or without adaptive equipment. Who assists?:Frequency:BLADDER CONTROL:Controls urination or uses devices (ostomy)Requires occasional verbal reminders to urinate or loses control of functions more than 2x week or lessRequires frequent verbal reminders to urinate or loses control of functions more then 2x wk.Unable to control urination - needs protective clothingAbility to perform bladder functionsWho assists?:Frequency:BOWEL CONTROL:Controls defecation or uses devices (ostomy)Requires occasional verbal reminders to defecate of loses control of functions 2x wk or lessRequires frequent verbal reminders to defecate or loses control of functions more than 2x wkUnable to control defecation – needs protective clothing.Ability to perform bowel functionsWho assists?:Frequency:TOILETING:Requires no assistance/ supervisionRequires occasional assistanceRequires substantial assistanceUnable to perform toileting independentlyGetting to/ from “toilet room, “transferring to/ from toilet, cleansing self, rearranging clothes, with or without adaptive equipment Who assists?:Frequency:WALKING/ MOBILITY:Requires no assistance/ supervision in walking or moving independently with assistive devicesRequires occasional assistanceRequires substantial assistanceUnable to walk or move from one place to another/ remains in bed all day.Ability to walk and move from one place to another inside or outside Who assists?:Frequency:TRANSFERS:Requires no assistance/ supervisionRequires occasional assistanceRequires substantial assistanceUnable to get out of chair or bedAbility to move in and out of chair or bed with or without assistive equipment. Who assists?:Frequency:EATING:Requires no assistance / supervisionRequires some assistance (cutting food, pouring liquids) or encouragement to eat.Requires substantial assistance to eat or requires presence of another person because of gagging, difficulty swallowing, etc.Unable to feed self; requires intravenous or tube feeding.Ability to get food or nourishment into the body after it has been prepared and made available Who assists?:Frequency:REVIEW OF INSTRUMENTAL ACTIVITIES OF DAILY LIVING ( IADL)Ability to use telephone: Operates telephone totally independently, looks up numbers, dials numbers Answers the telephone independently, but needs assistance dialing numbers Unable to use telephone at all. Shopping: Takes care of all shopping needs independently Can shop for small purchases and/ or is accompanied when shopping. Completely unable to shop Food Preparation: Plans, prepares and serves adequate meals independently. Heats and serves prepared meals or prepares some meals Needs to have all meals prepared and served. Housekeeping: Maintains house alone or with occasional assistance for “heavy” chores Performs light daily housekeeping tasks Needs help with all housekeeping and home maintenance tasks Laundry: Does personal laundry completely Launders small items- rinses socks, stocking, etc. All laundry must be done by others. Mode of Transportation: Travels independently on public transportation or drives own car Arranges own taxi or travels on public transportation when assisted or escorted. Travel limited to taxi or automobile with assistance from another or does not travel. Responsibility for own medications: Takes own medications in correct dosage at correct times Takes responsibility if medication is prepared in advance in separate dosages Is not capable of dispensing own medications Ability to Handle Finance: Manages all financial matters independently (budgets, writes checks, goes to bank) Manages day-to-day purchase, but needs help with banking, major purchases, etc. Incapable of handling money REVIEW OF BEHAVIORAL MANAGEMENTExhibits appropriate behaviorYesNoOccasionally exhibits behavior that requires monitoring and supervision:YesNoFrequently exhibits behavior that requires monitoring and supervision:YesNoExhibits behavior monitored and supervised by caregiver / family member which is often disruptive or dangerous to self or others and requires intervention:YesNoWho assists?:Frequency:Current ChallengesGoalsName of individual completing questionnaire:Date 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 This iframe contains the logic required to handle AJAX powered Gravity Forms.