Physician'S Report For Community Care Facilities Page 2
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3Ambulatory status of client/resident:
■ ■
■ ■
Yes
No
1. This person is able to independently transfer to and from bed:
2.
For purposes of a fire clearance, this person is considered:
■ ■
■ ■
■ ■
Ambulatory
Nonambulatory
Bedridden
Nonambulatory: A person who is unable to leave a building unassisted under emergency conditions. It includes any person who is unable, or
likely to be unable, to physically and mentally respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relating
to fire danger, and persons who depend upon mechanical aids such as crutches, walkers, and wheelchairs.
Note: A person who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be
considered non-ambulatory for the purposes of a fire clearance.
Bedridden: For the purpose of a fire clearance, this means a person who requires assistance with turning or repositioning in bed.
■ ■
■ ■
■ ■
COMMENTS:
I. PHYSICAL HEALTH STATUS:
GOOD
FAIR
POOR
YES
NO
ASSISTIVE DEVICE
COMMENTS:
(Check One)
1.
Auditory impairment
2.
Visual impairment
3.
Wears dentures
4.
Special diet
5.
Substance abuse problem
6.
Bowel impairment
7.
Bladder impairment
8.
Motor impairment
9.
Requires continuous bed care
■ ■
■ ■
■ ■
II. MENTAL HEALTH STATUS:
GOOD
FAIR
POOR
COMMENTS:
NO
OCCASIONAL
FREQUENT
IF PROBLEM EXISTS, PROVIDE COMMENT BELOW:
PROBLEM
1.
Confused
2.
Able to follow instructions
3.
Depressed
4.
Able to communicate
■ ■
■ ■
COMMENTS:
III. CAPACITY FOR SELF CARE:
YES
NO
YES
NO
COMMENTS:
(Check One)
1.
Able to care for all personal needs
2.
Can administer and store own medications
3.
Needs constant medical supervision
4.
Currently taking prescribed medications
5.
Bathes self
6.
Dresses self
7.
Feeds self
8.
Cares for his/her own toilet needs
9.
Able to leave facility unassisted
10. Able to ambulate without assistance
11. Able to manage own cash resources
PAGE 2 OF 3
LIC 602 (7/11)
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