Health Care Practitioner Physical Assessment Form Page 2
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Resident Name __________________________________
Date Completed ______________________
Date of Birth ____________________________________
5. History. Does the resident have a history or current problem related to abuse of prescription, non-prescription,
over-the-counter (OTC), illegal drugs, alcohol, inhalants, etc.?
(a)
Substance: OTC, non-prescription medication abuse or misuse
1. Recent (within the last 6 months)
Yes
No
2. History
Yes
No
(b)
Abuse or misuse of prescription medication or herbal supplements
1. Currently
Yes
No
2. Recent (within the last 6 months)
Yes
No
(c)
History of non-compliance with prescribed medication
1. Currently
Yes
No
2. Recent (within the last 6 months)
Yes
No
(d)
Describe misuse or abuse: _________________________________________________________
____________________________________________________________________________________
6.* Risk factors for falls and injury. Identify any conditions about this resident that increase his/her risk of falling or
injury (check all that apply):
orthostatic hypotension
osteoporosis
gait problem
impaired
balance
confusion
Parkinsonism
foot deformity
pain
assistive devices
other (explain)
__________________________________________________________________________________________
7.* Skin condition(s). Identify any history of or current ulcers, rashes, or skin tears with any standing treatment
orders. _________________________________________________________________________________
__________________________________________________________________________________________
8.* Sensory impairments affecting functioning. (Check all that apply.)
(a) Hearing:
Left ear:
Adequate
Poor
Deaf
Uses corrective aid
Right ear:
Adequate
Poor
Deaf
Uses corrective aid
(b) Vision:
Adequate
Poor
Uses corrective lenses
Blind (check all that apply) -
R
L
(c) Temperature Sensitivity:
Normal
Decreased sensation to:
Heat
Cold
9. Current Nutritional Status.
Height
inches
Weight
lbs.
(a) Any weight change (gain or loss) in the past 6 months?
Yes
No
(b) How much weight change?
lbs. in the past
months (check one)
Gain
Loss
(c) Monitoring necessary? (Check one.)
Yes
No
If items (a), (b), or (c) are checked, explain how and at what frequency monitoring is to occur: ___________
__________________________________________________________________________________________
(d) Is there evidence of malnutrition or risk for undernutrition?
Yes
No
(e)* Is there evidence of dehydration or a risk for dehydration?
Yes
No
(f) Monitoring of nutrition or hydration status necessary?
Yes
No
If items (d) or (e) are checked, explain how and at what frequency monitoring is to occur: _______________
__________________________________________________________________________________________
(g) Does the resident have medical or dental conditions affecting: (Check all that apply)
Chewing
Swallowing
Eating
Pocketing food
Tube feeding
(h) Note any special therapeutic diet (e.g., sodium restricted, renal, calorie, or no concentrated sweets
restricted): _________________________________________________________________________________
__________________________________________________________________________________________
(i) Modified consistency (e.g., pureed, mechanical soft, or thickened liquids): _________________________
__________________________________________________________________________________________
(j) Is there a need for assistive devices with eating (If yes, check all that apply):
Yes
No
Weighted spoon or built up fork
Plate guard
Special cup/glass
(k) Monitoring necessary? (Check one.)
Yes
No
If items (g), (h), or (i) are checked, please explain how and at what frequency monitoring is to occur:
__________________________________________________________________________________________
Form 4506
Revised 9-15-09
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