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Initial Assessment Form

	Personal Information
	Basic Information

	Please tell us about you:
	Name:
	Address:
	Phone:
	E-mail:
	Who is this assessment for:
	Name:
	Address:
	Phone:
	Date of Birth:
	Sex:
	Marital Status:
	Relationship:
	What is his/her living arrangement:
	With whom does he/she live:

	Medical Information
	Basic Medical Information

	How tall is he/she:
	How much does he/she weigh:
	Does he/she use a hearing aid:	Yes No
	Does he/she use a hospital bed:	Yes No
	Does he/she us an oxygen equipment:	Yes No
	What is his/her mental and emotional state:	Sad Anxious Wandering Forgetful Suspicious Confused Angry Delusional Withdrawn Suicidal
	When was his/her most recent doctor visit:
	When was his/her most recent hospitalization:
	What is his/her medical condition:

	Activities of Daily Living
	Bathing

	Which one best reflects his/her ability to bathe unassisted:
	How often does he/she like to bathe:
	If he/she has difficulty bathing unassisted, what causes this difficulty:	Getting into tub Standing Fatigue Limited range of motion Other

	Dressing

	Which one best reflects his/her ability to dress unassisted:
	If he/she has difficulty dressing unassisted, how does he/she manage:	Assistance from another person Minor assistance using a grab bar Require special adaptive closure like velcro Other

	Toileting

	Which one best reflects his/her ability to use the toilet in a timely manner:
	If he/she has difficulty using the toilet unassisted, how does he/she us the toilet:	Assistance from another person Minor assistance using special equipment Commode Diaper Other
	What condition causes this difficulty:	Weakness Poor balance Memory loss or confusion Paralysis Limited range of motion Pain Other
	Does he/she ever experience loss of control of the bladder or bowel:	Yes No
	What seems to be the cause of his/her loss of control of the bladder or bowel:	Physical activity Coughing or sneezing Occurs randomly Other
	If he/she uses special equipment to help manage incontinence, is he/she able to manage it unassisted:	Yes No

	Transferring

	Which one best reflects his/her ability to transfer to and from bed, chair or wheelchair:
	If he/she has difficulty transferring unassisted, how does he/she transfer:	Assistance from another person Mechanical assistance Minor assistance using adaptive or assistive device Other
	What condition causes this difficulty:	Weakness Poor balance Memory loss or confusion Paralysis Limited range of motion Pain Other

	Ambulating

	Which one best reflects his/her ability to walk unassisted:
	If he/she has difficulty walking unassisted, how does he/she walk:	Assistance from another person Mechanical assistance Minor assistance using a cane or walker Other
	What condition causes this difficulty:	Weakness Poor balance Leg pain Paralysis Limited range of motion Memory loss or confusion Other

	Eating

	How many meals does he/she eat a day:
	Once a meal has been served, which one best reflects his/her ability to eat unassisted:
	What difficulties does he/she experience while eating:	Chewing Swallowing Cutting Other

	Instrumental Activities of Daily Living
	Medications

	Which one best reflects his/her ability to self-administer medications safely and appropriately:
	Does he/she have any help managing medications:	Assisted by family or friends Agency assistance Pillbox Other

	Handling Finances

	Which one best reflects his/her ability to manage financial affairs:
	Does he/she have any help managing finances:	Family members Friends Neighbor Lawyer Accountant Other

	Grocery Shopping

	Which one best reflects his/her ability to go grocery shopping:
	When he/she goes shopping, how does he/she usually get there:	Drives Family, friend or neighbor drives Public transportation Shuttle service Walks Other

	Meal Preparation

	Which one best reflects his/her ability to prepare own meals:
	Has he/she been in any kitchen accidents within the last 12 months:	Yes No
	If he/she has difficulty preparing meals unassisted, how does he/she prepare meals:	Family, friend or neighbor Meals on wheels Other

	Housework

	Which one best reflects his/her ability to perform basic housework:
	If he/she has difficulty performing basic housework unassisted, how does he/she perform basic housework:	Family, friend or neighbor Housekeeping service Other

	Financial
	Financial Information

	What are the primary sources of his/her income:	Employment income Pension Investments Disability Social security Supplemental security income Family contributions Other
	Please indicate what types of health insurance coverage he/she has:	Private insurance Medicare Part A Medicare Part B Medicaid Long-term care insurance Medi-Gap Other

	Psychosocial
	Psychosocial Information

	Which of these care services does he/she use:	Personal care Home health care Adult day care Support groups Meals on wheels Emergency response system Transportation Cleaning Other
	Has he/she experienced any of these major life transitions in the last 12 months:	Moved Loss of spouse Loss of loved one other than spouse New medical condition

Thank you for completing the initial assessment form.