Form Doh 3122 - Assisted Living Residence Medical Evaluation Form - New York

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ASSISTED LIVING RESIDENCE
New York State Department of Health
MEDICAL EVALUATION
Division of Assisted Living
ALL SPACES MUST BE FILLED OUT
Resident’s Name: __________________________________________________________
Date of Exam: _________
Facility Name: ________________________________________ Date of Birth:__________ Sex:_______
Present Home Address:____________________________________________________________________________
Street
City
State
Zip

Reason for evaluation:  Pre-Admission  12 month  Acute change in condition
Other :_____________________
MEDICAL REVIEW FINDINGS
Vital Signs: BP: _______ Pulse:_____ Resp: _______ T: _______ Height: _____ft _____in. Weight: _______
Primary Diagnosis(s): _____________________________________________________________________________
________________________________________________________________________________________________________
Secondary Diagnosis(s): ___________________________________________________________________________
_______________________________________________________________________________________________
Allergies:  None or list Known Allergies: ___________________________________________________________
Diet:  Regular  No Added Salt  No Concentrated Sweets  Other: ________________________


Immunizations:
Influenza (Date_____________)
Pneumococcal Vaccine (Date_____________)
TB SCREENING (performed within 30 days prior to initial admission unless medically contraindicated)
Test is contraindicated
Test:  TST1
 TST2
TB Blood Test (Type)____________ Date______ Result_______
TST1: Date placed______
Date Read______
mm______
TST2: Date placed______
Date Read______
mm______
Based on my findings and on my knowledge of this patient, I find that the patient _______ IS _______ IS NOT exhibiting signs
or symptoms suggestive of communicable disease that could be transmitted through casual contact.
CONTINENCE




Bladder: Yes
No
If no, is incontinence managed? Yes
No




Bowel:
Yes
No
If no, is incontinence managed? Yes
No
If no, recommendations for management:__________________________________________________________________

LABORATORY SERVICES:
None
Lab Test
Reason/Frequency
Lab Test
Reason/Frequency
________________
_______________________________
________________
_________________________
__________________
__________________________________
_________________
____________________________
DOH 3122 (3/09) Rev. 5/12
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