Alwp Client Inquiry Pre-Screen Form Page 2

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ALWP PRE- SCREEN ASSESSMENT
PLEASE COMPLETE ALL QUESTIONS TO THE BEST OF YOUR ABILITY
SCORING:
0 = Independent
1 = Supervision/Overseeing
2 = Limited Assistance needed
3 = Extensive Assistance
4 = Total Dependence
Please circle and enter Total
Total
0
1
2
3
4
BED MOBILITY – (how client moves and positions self)
0
1
2
3
4
TRANSFER – (how client moves between surfaces)
0
1
2
3
4
LOCOMOTION IN RESIDENCE – (how client moves in room and area of residence )
DRESSING – (how clients puts on, fastens, and takes off clothing)
0
1
2
3
4
0
1
2
3
4
EATING – (how clients eats and drinks, getting meals)
0
1
2
3
4
TOILET USE / INCONTINENT - (Transfers on/off toilet, or commode, bedpan, urinal)
0
1
2
3
4
PERSONAL HYGIENE – (how client maintains personal hygiene)
0
1
2
3
4
BATHING – (how client takes body bath/shower)
0
4
DOES THE CLIENT HAVE OXYGEN
(no = 0 yes = 4)
0
DOES THE CLIENT HAVE A NEBULIZER / BREATHING TREATMENTS (no = 0 yes = 2)
2
MEDICATIONS
Five or less meds enter 0. Six or more meds enter 2
<5
0
6>
2
(Include all over-the-counter, supplemental, and alternative medications)
Is the client physically capable of taking medications without assistance
0
YES
1
NO
Does the client know what the medications are for?
0
YES
1
NO
Does the client know how to take the medications? (proper route)
0
YES
1
NO
Does the client know how often to take the medications?
0
YES
1
NO
Is the client capable of communicating if the medication has had the desired effect or
0
YES
1
NO
unintended side effects?
PLEASE ALSO ATTACH A COPY OF THE PHYSICIANS REPORT
Total Score
□
□
Have you ever been enrolled in the Assisted Living Waiver Program?
YES
NO
□
□
Is the client enrolled in a MediCal Health Plan?
YES
NO
□
□
Has the client completed the Medi-Cal Waiver Program Exemption form?
YES
NO
□
□
Is the client enrolled in either SCAN or PACE?
YES
NO
□
□
Does the client receive dialysis?
YES
NO
□
□
Is there evidence that the client is interested in the Assisted Living Waiver Program (ALWP) ?
YES
NO
□
□
Does the client receive IHSS services?
YES
NO
please Attach Physicians report
:
List of Primary Diagnoses and
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
List of Prescription medications:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

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