assessment form for assisted living

Resident Health and Functional Status Evaluation

Instructions for Use

• Complete all sections of this form in blue or black ink to ensure accurate record-keeping and regulatory compliance.
• Ensure the prospective resident or their legal representative reviews and initials each page to acknowledge the accuracy of the documented health status.
• Maintain the original signed document in the resident’s permanent clinical file and provide a copy to the resident or their authorized representative upon request.

Parties and Definitions

This evaluation is conducted by [Facility Name] ("Facility") regarding the prospective resident, [Prospective Resident Name] ("Resident"). The "Legal Representative" is defined as [Name of Legal Representative], acting as [Power of Attorney/Guardian/Other]. The "Evaluation Date" is [Date of Assessment].

Operative Clauses

1. Activities of Daily Living (ADLs): The Resident requires the following level of assistance for daily tasks (Check one for each):

   • Bathing: [ ] Independent [ ] Supervision [ ] Hands-on Assistance
   • Dressing: [ ] Independent [ ] Supervision [ ] Hands-on Assistance
   • Toileting: [ ] Independent [ ] Supervision [ ] Hands-on Assistance
   • Transferring: [ ] Independent [ ] Supervision [ ] Hands-on Assistance
   • Eating: [ ] Independent [ ] Supervision [ ] Hands-on Assistance

2. Cognitive and Behavioral Status: The Resident displays the following cognitive patterns:

   • Orientation: [ ] Alert and Oriented [ ] Mild Confusion [ ] Significant Impairment
   • Memory: [ ] Intact [ ] Short-term deficits [ ] Long-term deficits
   • Behavioral History: [ ] No history of wandering/aggression [ ] History of [__________]

3. Medical and Clinical Needs:

   • Current Diagnoses: [__________]
   • Medication Management: [ ] Self-Administered [ ] Staff-Assisted [ ] Staff-Administered
   • Specialized Equipment: [ ] Oxygen [ ] Wheelchair [ ] Walker [ ] Other: [__________]

4. Nutritional and Dietary Requirements:

   • The Resident requires the following diet: [__________]
   • Known Food Allergies: [__________]

5. Facility Capacity to Provide Care: The Facility confirms that it possesses the staff, training, and environmental resources necessary to meet the needs identified in this assessment, subject to periodic reassessment as required by state law.

6. Periodic Reassessment: This document shall be reviewed at least [Number] months from the Evaluation Date, or immediately following a significant change in the Resident’s physical or mental health status.

Signature and Acknowledgment

By signing below, the parties acknowledge that the information provided is accurate to the best of their knowledge and that the Facility is capable of providing the necessary level of care.

Facility Representative: __________ Printed Name: [Name of Staff Member] Title: [Job Title] Date: [__________]

Resident/Legal Representative: __________ Printed Name: [Name of Signatory] Title: [Relationship to Resident] Date: [__________]

Legal Disclaimer: This document is a general framework and does not constitute legal advice. Requirements for health evaluations vary significantly by state and local jurisdiction. Consult with qualified legal counsel to ensure this document complies with all applicable state-specific statutes and healthcare regulations.