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Initial Assessment Form

This form is mandatory for pre-residential determination

Please note the following before filling out this form: Under Maryland regulations an assisted living program may 
not provide services to a resident who, at the time of initial admission, as established by the initial assessment, 
requires: (1) More than intermittent nursing care: (2) Treatment of stage three or stage four skin ulcers; (3) Ventilator services; (4) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition: (5) Monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; or (6) Treatment for a disease or condition that requires more than contact isolation. An exception to the conditions Iisted above is provided for residents who are under the care of a licensed general hospice program.: 

Healthcare Practitioner Physical Assessment Form

This Form is to be completed be a Primary Physician, Certified Nurse Practitioner, Registered Nurse, Certified Nurse Midwife or Physicians Assistant.

4. Is the resident free from Communicable TB and any other active reportable airborne communicable disease.
Which test were done to verify that the resident is free of active TB

5. Does the resident have a history or current problem related to abuse of prescription, non-prescription, over-the-counter (OTC), illegal drugs, alcohol, inhalants, etc.?

6. Risk factors for falls and injury. Indentify any conditions about ths resident that increases his/her risk of falling or injury. (Check all tha apply)
8. Sensory Impairments affecting functioning
Sensory Impairments Affecting functioning
a. Any weight change in the last six months?
c. Monitoring necessary?
d. Is there evidence of malnutrition or risk of undernutriton?
e. Is there evidence of dehydration or a risk of dehydration?
f. Monitoring of nutrition or hydration status necessary?
g. Does the resident have medical or dental conditions effecting: (Check all that apply)
j. Is there a need for assistive devices with eating?
(Check all that apply)
k. Monitoring necessary?
a. Is there evidence of dementia?
b. Has the resident undergone an evaluation for dementia?
c. Diagnosis (Cause(s) of Dementia)
I. Disorientation.
II. Impaired Recall (recent/distant events)
III. Impaired Judgement.
IV. Hallucination.
V. Delusions.
VI. Receptive/Expressive Aphasia.
VII. Anxiety.
VIII. Depression.
IX. Unsafe Behaviors.
X. Dangerous to self or others.
XI. Agitation (descibe behavior in comments).
10f. Health care decision-making capacity. Based on the preceding review of functional capabilites, physical and cognitive status, and limitations, indicate this resident's highest level of ability to make health care decisions.
11. * Ability to self-administer medications. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, rate this resident's ability to take his/her own medications safely and appropriately.
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