Health Care Practitioner Physical Assessment Form printable pdf download

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

Health Care Practitioner Physical Assessment Form

This form is to be completed by a primary physician, certified nurse practitioner, registered nurse, certified nurse-

midwife or physician assistant. Questions noted with an asterisk are “triggers” for awake overnight staff.

Please note the following before filling out this form: Under Maryland regulations an assisted living program may

not provide services to a resident who, at the time of initial admission, as established by the initial assessment,

requires: (1) More than intermittent nursing care; (2) Treatment of stage three or stage four skin ulcers; (3)

Ventilator services; (4) Skilled monitoring, testing, and aggressive adjustment of medications and treatments

where there is the presence of, or risk for, a fluctuating acute condition; (5) Monitoring of a chronic medical

condition that is not controllable through readily available medications and treatments; or (6) Treatment for a

disease or condition that requires more than contact isolation. An exception to the conditions listed above is

provided for residents who are under the care of a licensed general hospice program.

1.* Current Medical and Psychiatric History. Briefly describe recent changes in health or behavioral status, suicide

attempts, hospitalizations, falls, etc., within the past 6 months.

2.* Briefly describe any past illnesses or chronic conditions (including hospitalizations), past suicide attempts,

physical, functional, and psychological condition changes over the years.

3. Allergies. List any allergies or sensitivities to food, medications, or environmental factors, and if known, the

nature of the problem (e.g., rash, anaphylactic reaction, GI symptom, etc.). Please enter medication allergies

here and also in Item 12 for medication allergies.

4. Communicable Diseases. Is the resident free from communicable TB and any other active reportable airborne

communicable disease(s)?

(Check one)

Yes

If “No,” then indicate the communicable disease: ________________________

Which tests were done to verify the resident is free from active TB?

PPD

Date: __________ Result:___________mm

Chest X-Ray (if PPD positive or unable to administer a PPD)

Date: __________ Result_____________

Form 4506

Revised 9-15-09

Health Care Practitioner Physical Assessment Form