Application For Admission To The New York Armenian Home Page 9
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10SUBSTITUTE FOR DSS-3122
MEDICAL EVALUATION
(6/96)
(ALL SPACES MUST BE COMPLETED)
STATEMENT OF PURPOSE
Adult Residential Care Program provide 24 hour residential care settings for dependent adults. They are not medical facilities. Persons in need of
constant medical care and supervision should not be admitted or retained in an adult residential care facility because such a facility lacks the staff and
expertise to provide needed services. Persons who, by reason of age and/or physical and/or mental limitations, are in need of assistance with the basic
activities of daily living can be cared for in adult residential care settings.
The information solicited in this medical evaluation will assist you, the individual, and the operator of an adult residential care facility in determining
level of care needed to assure the health, safety and well being of the individual. It will become part of the resident’s record and subject to review by
the Department of Social Services, which is responsible for supervision of the Adult Residential Care Programs.
SECTION I: PERSONAL
NAME: _______________________________________________
DATE OF BIRTH: _____/ _____/ _____
ADDRESS: _______________________________________________
________________________________________________
SEX:
M
F
SECTION II: MEDICAL HISTORY
PRIMARY DIAGNOSIS:
SECONDARY DIAGNOSIS:
RECENT SURGERY: (Type of procedure)
___ None Known.
RECENT ACUTE ILLNESS: (Type and Date)
DIET:
ALLERGIES TO : (List any known)
___ None Known
REGULAR…………………………………………… _____
MEDICATIONS:
___ NONE
LOW SALT…………………………………………. _____
FOOD:
___ NONE
LOW SUGAR/NCS…………………………………. _____
OTHER:
___ NONE
WE SERVE 1-2% FAT MILK AND SPECIAL DESERTS FOR DIABETIC DIET
ACTIVITY RESTRICTIONS:
___ NONE
WEIGHT BEARING:
CHRONIC ILLNESS, PHYSICAL OR MENTAL LIMITATIONS
FULL:
PPD (mantoux) test date _______________ Results ___________
PARTIAL:
BLOOD PRESSURE:
NONE:
WEIGHT:
REQUIRED MEDICAL EXAMINATIONS AND/OR COMMUNITY BASED MEDICAL SERVICES:
REQUIRED NEED
PROVIDED BY
FREQUENCY
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
OVER
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