Lic 9172 - Functional Capability Assessment Page 2
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2Describe client’s medical history and/or conditions:
List prescription medicine:
List non-prescription medicine:
Describe mental and/or emotional status:
I I
I I
I I
I I
Able to follow instructions?
YES
NO
Confused/disoriented?
YES
NO
I I
I I
I I
I I
Participates in social activities?
YES
NO
Active
Withdrawn
I I
I I
Is there a history of behaviors resulting in harm to self or others that require supervision?
YES
NO
If YES, provide date__________________________ and describe last occurrence:
I I
I I
Does he/she have ability to manage own finances and cash resources?
YES
NO
I I
I I
Is there any additional information that would assist the facility in determining client’s
YES
NO
suitability for admission? If YES, describe:
SIGNATURE OF APPLICANT OR AUTHORIZED REPRESENTATIVE
DATE COMPLETED
SIGNATURE OF LICENSEE OR FACILITY REPRESENTATIVE
DATE COMPLETED
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Parent category: Medical