Form Doh 3122 - Assisted Living Residence Medical Evaluation Form

ASSISTED LIVING RESIDENCE

New York State Department of Health

MEDICAL EVALUATION

Division of Assisted Living

Patient/Resident Name: ______________________________________________

Date:

__________________________

ACTIVITIES OF DAILY LIVING (ADL’s)

Activity Restrictions: No 

Yes  (describe):____________________________________________________________

Dependent on Medical Equipment: No 

Yes  (describe):_________________________________________________

Level and frequency of assistance required/needed by the resident of another person to perform the following:

Independent 

 Continual 

1. Ambulate:

Intermittent

Independent 

 Continual 

2. Transfer:

Intermittent

Independent 

 Continual 

3. Feeding:

Intermittent

4. Manage Medical Equipment: Manages Independently 

Cannot Manage Independently 

ADDITIONAL SERVICES IF INDICATED BY RESIDENT NEED:

Pertinent medical/mental findings requiring follow-up by facility (e.g. skin conditions/acute or chronic pain issues)

None  or if yes, describe_____________________________

or any additional recommendations for follow-up:

____________________________________________________________________________________________________________

 None Yes (specify):  Physical Therapy Speech Therapy Occupational Therapy

Therapies:

Home Care:  None Yes (specify):__________________________ Other (Specify):__________________________

⁯

Is Palliative Care Appropriate/Recommended: No

If yes, describe services: ______________________________

COGNITIVE IMPAIRMENT/MEMORY LOSS (including dementia)

Does the patient have/show signs of dementia or other cognitive impairment? ⁯ No

⁯ Yes

If yes, do you recommended testing be performed? ⁯ No ⁯ If yes, referral to:______________________________________

If testing has already been performed, date/place of testing if known:______________________________________________

MENTAL HEALTH ASSESSMENT (non-dementia)

⁯

Does the patient have a history of or a current mental disability?

Yes

⁯

Has the patient ever been hospitalized for a mental health condition?

Yes

If yes, describe:

____________________________________________________________________________________________

Based on your examination, would you recommend the patient seek a mental health evaluation? (If yes, provide referral)



Yes Describe: ______________________________________________________________________________

MEDICATIONS

Pursuant to NYCRR Title 18 487.7(f)(2), the patient is NOT capable of self-administration of medication if he/she needs assistance to properly carry

out ONE OR MORE of the following tasks:

 Correctly read the label on a medication container

 Correctly follow instructions as the route, time dosage and frequency

 Correctly ingest, inject or apply the medication

 Measure or prepare medications, including mixing, shaking and filling

 Open the container

syringes

 Safely store the medication

 Correctly interpret the label

DOH 3122 (3/09) Rev. 5/12

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Form Doh 3122 - Assisted Living Residence Medical Evaluation Form - New York Page 2

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