Medical Evaluation Form - Group Homes Page 2
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4MEDICAL EVALUATION FORM
Allergies
(Please list): _____________________________________________________
Blood pressure:__________________________
Pulse: _______________________________
BSL:___________________________
Weight: ___________ Height: _____________________
Assistance with Mobility
Independent
Yes
No
Supervision with walking
Yes
No
Mechanical Aid (frame, wheelchair, stick etc)
Yes
No
Hearing Aids
Yes
No
Glasses
Yes
No
Continence
Continent of urine
Yes
No
Continent of faeces
Yes
No
Does the patient have a diagnosis of Dementia:
Yes
No
If yes, which type:
Alzheimer’s
Undifferentiated
Vascular
Mixed
In the case of a diagnosis of dementia, the patient will require a valid (done within 6 months) report from a
Psychogeriatrician.
Does the patient have symptoms of depression:
☐ Yes
☐ No
More Information:__________________________________________________________________
________________________________________________________________________________
MEDICAL EVALUATION FORM.doc
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