Individual's HEALTH ASSESSMENT for
HEALTH CARE PROVIDER
TO BE COMPLETED BY HEALTH CARE PROVIDER
Individual's Name and DOB:
Known Allergies: Height: Weight:
Medical history and diagnoses:
Physical or sensory limitations:
Cognitive or behavioral status:
Nursing/treatment/therapy service
requirements:
Special precautions:
A. To what extent does the individual
need supervision or
assistance with the following?
S=Needs Supervision I= Independent A=
Needs Assistance
Indicate the extent to which the
individuals is able to
perform each of the activities of daily
living.
Ambulation
Bathing
Dressing
Eating
Self Care (grooming)
Toileting
Transferring
Special Diet Instructions
Regular Calorie Controlled No Added
Salt Low Fat/Low
Cholesterol
Does the individual have any of the
following
conditions/requirements? Please include
an explanation
1. A communicable
disease, which could be transmitted to
others
2. Bedridden?
3. Any stage 2, 3, or 4
pressure sores?
Pose a danger to self
or others
Require 24-hour nursing
or psychiatric care?'
In your opinion,
can this individual's
needs be met by this caregiver
ABILITY TO PERFORM SELF-CARE TASKS:
Preparing Meals
Shopping
Making and Receiving Phone Calls
Handling Personal Affairs
Handling Financial Affairs
GENERAL OVERSIGHT:
Observing Well-being
Observing Whereabouts
Reminders for Important Tasks
ADDITIONAL COMMENTS/OBSERVATIONS (Use
additional page if
necessary):
list all current medications prescribed
below
MEDICATION DOSAGE DIRECTIONS FOR
USE ROUTE
1.
2.
Does the individual need help with
taking his or her
medications
=
PLEASE RETURN TO:
CARE PROVIDER NAME:
CARE PROVIDER ADDRESS:
TELEPHONE NUMBER: CONTACT PERSON:
