Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) Page 12
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15AG-095 (11-14) – Page 12
CLIENT’S NAME
DAARS ID NO.
Sight/Hearing
Acute
History
Other
Acute
History
Blindness ..............................................
Reduced physical stamina/frailty ............
Cataract ................................................
Birth defect .............................................
Glaucoma .............................................
Fibromyalgia ..........................................
Macular degeneration ...........................
Dehydration ............................................
Otitis media ..........................................
Other:
...........
Hearing deficit ......................................
Other:
...........
COMMENTS
COMMENTS
Skin Conditions
Acute
History
None
Decubitus .............................................
List the category and name of no more than 3 conditions
Cellulitis ................................................
that have a current effect on the client:
Category
Condition
COMMENTS
Information provided by:
Client
Informal caregiver
Other, specify:
G. Nursing Services and Treatment
For each service, select S for single/one-time or C for continuous. If the client currently receives the service from a Non-Area Agency on
Aging Source, select the box below Receives. If no services are needed, select None.
Frequency
Receives
Comments
C
S
Insulin set up ........................................
Medication setup ..................................
Vital monitoring .....................................
Nursing assessment .............................
Teaching by nurse ................................
Medication management/monitoring .....
Wound care ..........................................
Catheter colostomy care .......................
None ............................................
H. Hospitalization/ER Visits/Falls
How many times have you been
How many times have you been seen in the
How many times have you fallen in the past
hospitalized in the past 6 months?
emergency room in the past 6 months?
6 months?
None
None
None
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