Name of Resident
Age
Weight
Current Location
In general, how would you rate their health?
Very Good
Good
Fair
Poor
Does the resident have any of these health issues?
Kidney Problems
Diabetes
Stroke
Liver Problems
COPD (Lung Disease)
Heart Problems
Cancer
Alzheimer's / Dementia
Other (Please Specify)
Please provide details on above health issue/s:
Does the resident need assistance with any of the following?
Eating
Walking
Getting dressed
Getting in or out of a bed / chair
Using the toilet
Seeing
Hearing
Taking a bath / shower
Please list all medications:
Does resident currently smoke or use tobacco?
Yes
No
Any problems with balance or walking in the past 12 months?
Yes
No
How many falls in the past year?
0
(1-5)
(6+)
Does resident have trouble sleeping at night?
Yes
No
How many times do they get out of bed at night?
(1-3)
(4+)
Is resident ambulatory?
Yes
No
If incontinent, approximately how many times throughout the day?
(1-4)
(5+)
Can they bear their own weight?
Yes
No
How does the resident require assistance when transferring?
1 person assist
2 person assist
Hoyer Lift
Does the resident have any behavioral issues?
Agitation
Aggressiveness
Combative
Yells at night
Refuses food / drink
Depression
Unsocial
Refuses medication
Please provide any additional information
Does resident require a special diet?
Does resident have any allergies?
Does resident have any recent infections?
Does the resident use any of the following?
Oxygen Catheter
Wheelchair
Hospital Bed
Walker / Cane
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