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First Name *

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Contact Phone Number *

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City*

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Advance Assessment Details

PAYOR TYPE*

Private Pay Medicare A Medicare B Private insurance

MEDICATIONS*

Once a day Twice a day Three times a day Four times a day

INCONTINENCE*

Manage once a day Manage twice a day Manage thrice a day Manage more than thrice a day

WOUND CARE*

Stage 1 Stage 2 Stage 3 Stage 4

DIALYSIS*

Thrice a week More than three times a week

COLOSTOMY BAG*

Change 1-3 times a day Change 1-3 times a week

GASTRONOMY TUBE*

Yes No

FEEDING TUBE*

Yes No

POSITIONING IN BED*

Once a day Twice a day Three times a day Four times a day or more

POSITIONING IN CHAIR*

Once a day Twice a day Three times a day Four times a day or more

TRANSPORTATION*

Once a week Twice a week Thrice a week More than three times a week

LAUNDRY*

Once a week Twice a week Thrice a week More than three times a week

HOUSEKEEPING*

Once a week Twice a week Thrice a week More than three times a week

FEEDING*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

BRUSH HAIR*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

APPLY MAKE UP*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

SHAMPOO HAIR*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

DRY HAIR*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

BRUSH TEETH*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

SHAVING*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

UPPER BODY DRESSING (DONNING AND DOFFING OF SHIRT/BLOUSE)*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

LOWER BODY DRESSING (DONNING AND DOFFING OF SKIRT/PANTS/GOWNS)*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

UPPER BODY BATHING*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

LOWER BODY BATHING*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

AMBULATION WITHOUT DEVICE*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

AMBULATION WITH CANE*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

AMBULATION WITH WALKER*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

WHEELCHAIR MOBILITY*

No assistance Require supervision without instruction Require supervision with instructions Require 25% physical assistance Require 50% physical assistance Require 75% physical assistance Require 100% physical assistance

SAFETY ALERT*

ORIENTED TO PERSON ONLY ORIENTED TO PLACE ONLY ORIENTED TO TIME ONLY ORIENTED TO PERSON, PLACE AND TIME

SAFETY DIRECTIONS*

FOLLOW ONE STEP DIRECTION FOLLOW TWO STEP DIRECTION FOLLOW MULTIPLE STEP DIRECTION

RISK FOR FALLS*

Yes No

FREQUENCY OF FALLS*

Once a day More than once a day Once a week More than once a week Twice a year

WELL-BEING CHECK (DAY)*

Once an hour Once every two hours Once every four hours

WELL-BEING CHECK ((NIGHT))*

Once every half hour Once every one hour Once every two hour

REQUIRE HOSPICE CARE*

Yes No

DIAGNOSIS ALZHEIMERS DISEASE*

Yes No

UNDIAGNOSED DEMENTIA*

Yes No

COGNITIVE IMPAIREMENT*

Yes No

SHORT TERM MEMORY LOSS*

Yes No

LONG TERM MEMORY LOSS*

Yes No

COMBATIVENES*

Yes No

AGITATION*

Yes No

WANDER*

Yes No

AGRESSION*

Yes No

ELOPEMENT*

Yes No

ANXIOUS*

Yes No

DEPRESSION*

Yes No

Please choose all required options

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