Level of Care Assessment Form

How to complete the form: For most people this form is best completed online. Simply fill in the form in your screen and click the submit button below. Please complete the information so as to help us preparing a more accurate assessment of the level of care.

 

::. BASIC INFORMATION ABOUT THE RESIDENT

 

Prospective Resident Name

                               Age 

                               Sex  Male    Female

                            Height        Weight

 

           Current Residence

           Reason for moving

Contact Name

Address

Contact Name

Address

City

State

ZIP Code

Relationship

Phone

Cell/Phone

Email

 

            Medical Diagnosis

 

 

Activities of Daily Living.  Please answer the following questions based on the present condition of the resident.

 YES NO
Is help necessary for dressing your upper body?

Is help necessary for dressing your lower body?

Help with hygiene:
     washing hands & face

     hair, teeth, make up, shaving

     using toilet/incontinence issues

     bathing or showering

Is help necessary for getting in & out of bed/chair?

Is help necessary with wheelchair or walking? 

Is help necessary with dining:

     set up/cutting up food

     eating/self feeding/total assist if choking hazard 

Is help necessary with bed mobility: turning & positioning in bed

Do you use a walker?

Do you use a wheelchair?

Bowel and bladder function:
     bowel: incontinence

     bladder: incontinence

     requires a condom catheter

     foley catheter

Mental & cognitive status:
      disoriented (either time, place, person, things)

      memory loss (short term &/or long term)

      depression

     wanders

      exit seeking

Any behavior problem:
       physical/verbal/agitation/anxiety/uncooperative/resistant with care

       please explain here:

Others:
       medication assistance

       wound care treatment

       needs daily pain management

       requires injections

     Please specify & how often
      on feeding tube

Diabetic:

       insulin dependent 

       diet controlled

       blood glucose check: how often, specify
       on sliding scale insulin: how often, specify
       needing insulin injection: how many times a day, specify
Oxygen Therapy

Needs night care

Awake/calls approx. how many times at night

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Develop by Access Care Business Solutions, Seattle, USA