A newsbasket is on-line Internet publication containing comprehensive aggregated collections of information.


Individual's HEALTH ASSESSMENT for HEALTH CARE PROVIDER

Individual's HEALTH ASSESSMENT for HEALTH CARE PROVIDER

TO BE COMPLETED BY HEALTH CARE PROVIDER

Individual's  Name and DOB:
Known Allergies: Height: Weight:
Medical history and diagnoses:
Physical or sensory limitations:
Cognitive or behavioral status:
Nursing/treatment/therapy service requirements:
Special precautions:


A. To what extent does the individual need supervision or
assistance with the following?
S=Needs Supervision I= Independent A= Needs Assistance

Indicate the extent to which the individuals is able to
perform each of the activities of daily living.

Ambulation
Bathing
Dressing
Eating
Self Care (grooming)
Toileting
Transferring

Special Diet Instructions
Regular Calorie Controlled No Added Salt Low Fat/Low
Cholesterol


Does the individual have any of the following
conditions/requirements? Please include an explanation

  1. 1. A communicable disease, which could be transmitted to
  2. others
  3. 2. Bedridden?
  4. 3. Any stage 2, 3, or 4 pressure sores?
  5. Pose a danger to self or others
  6. Require 24-hour nursing or psychiatric care?'
  7. In your opinion,
  8. can this individual's needs be met by this caregiver

ABILITY TO PERFORM SELF-CARE TASKS:

Preparing Meals
Shopping
Making and Receiving Phone Calls
Handling Personal Affairs
Handling Financial Affairs
GENERAL OVERSIGHT:
Observing Well-being
Observing Whereabouts
Reminders for Important Tasks
ADDITIONAL COMMENTS/OBSERVATIONS (Use additional page if
necessary):

list all current medications prescribed below

MEDICATION DOSAGE DIRECTIONS FOR USE ROUTE
1.
2.
Does the individual need help with taking his or her
medications


=
PLEASE RETURN TO:  
CARE PROVIDER NAME: 
CARE PROVIDER ADDRESS: 
TELEPHONE NUMBER: CONTACT PERSON: