Health Screening Form Page 2
ADVERTISEMENT
1
2
3Other Services and
Treatment Orders
(Oxygen, PT, OT, Home Health,
Hospice, etc)
Current Medications
(including over the counter)
Is Resident Capable of Administering Own Medications?
Y
N
(Must be able to read and understand medication labels and meds taken)
TB Screening
(Date and Results)
Previous Positive-give presence or
Absence of symptoms
Can services be met in Assisted Living or
Y
N
Residential Care Community
Resident Requires Sleep Time Supervision
(Facility Must Have Awake Staff)
Y
N
Advance Directive
Y
N
FUNCTIONAL LEVEL
Section
3
Sight
Not Impaired
Impaired
Blind
Hearing
Not Impaired
Impaired
Deaf
Speech
Not Impaired
Impaired
Aphasic
ACTIVITIES OF DAILY LIVING
Self
With Assistance
Total Assist
Eating
Bathing
Dressing
Toileting
Continent
Incontinent
Catheter
Urinary
Bowel
Continent
Incontinent
Colostomy
Mobility
Ambulatory
Cane/Walker
Wheelchair
Bedfast
1 person
2 person
Mobility Assistance
Total Assist
3
Medical Assessment Form 032106
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical