Health Care Practitioner Physical Assessment Form Page 3
ADVERTISEMENT
1
2
3
4
53
Resident Name __________________________________
Date Completed ______________________
Date of Birth ____________________________________
10.* Cognitive/Behavioral Status.
(a)* Is there evidence of dementia? (Check one.)
Yes
No
(b) Has the resident undergone an evaluation for dementia?
Yes
No
(c)* Diagnosis (cause(s) of dementia):
Alzheimer’s Disease
Multi-infarct/Vascular
Parkinson’s Disease
Other
(d)
Mini-Mental Status Exam (if tested)
Date ______________ Score ______________
10(e)* Instructions for the following items: For each item, circle the appropriate level of frequency or intensity,
depending on the item. Use the “Comments” column to provide any relevant details.
Item 10(e)
A
B*
C*
D*
Comments
Cognition
I. Disorientation
Never
Occasional
Regular
Continuous
II. Impaired recall
Never
Occasional
Regular
Continuous
(recent/distant events)
III. Impaired judgment
Never
Occasional
Regular
Continuous
IV. Hallucinations
Never
Occasional
Regular
Continuous
V. Delusions
Never
Occasional
Regular
Continuous
Communication
VI. Receptive/expressive
Never
Occasional
Regular
Continuous
aphasia
Mood and Emotions
VII. Anxiety
Never
Occasional
Regular
Continuous
VIII. Depression
Never
Occasional
Regular
Continuous
Behaviors
IX. Unsafe behaviors
Never
Occasional
Regular
Continuous
X. Dangerous to self or
Never
Occasional
Regular
Continuous
others
XI. Agitation (Describe
behaviors in comments
Never
Occasional
Regular
Continuous
section)
10(f) Health care decision-making capacity. Based on the preceding review of functional capabilities, physical and
cognitive status, and limitations, indicate this resident’s highest level of ability to make health care decisions.
(a) Probably can make higher level decisions (such as whether to undergo or withdraw life-sustaining
treatments that require understanding the nature, probable consequences, burdens, and risks of
proposed treatment).
(b) Probably can make limited decisions that require simple understanding.
(c) Probably can express agreement with decisions proposed by someone else.
(d) Cannot effectively participate in any kind of health care decision-making.
11.* Ability to self-administer medications. Based on the preceding review of functional capabilities, physical and
cognitive status, and limitations, rate this resident’s ability to take his/her own medications safely and
appropriately.
(a) Independently without assistance
(b) Can do so with physical assistance, reminders, or supervision only
(c) Need to have medications administered by someone else
___________________________________
________________
Print Name
Date
______________________________________
Signature of Health Care Practitioner
Form 4506
Revised 9-15-09
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical