assisted living resident assessment form

Resident Functional and Clinical Evaluation Form

Instructions for Use

• This evaluation must be completed by a licensed healthcare professional or authorized clinical staff member prior to the resident's move-in date.
• Ensure all sections are completed in full; do not leave fields blank. Use "N/A" if a specific category does not apply to the resident.
• Once finalized, this document must be stored in the resident’s secure medical file and reviewed at least every six months or upon a significant change in condition.

Parties and Definitions

Facility Name: [] Resident Full Name: [] Date of Assessment: [] Assessor Name/Title: []

Definitions:

• ADLs: Activities of Daily Living, including bathing, dressing, grooming, toileting, transferring, and eating.
• IADLs: Instrumental Activities of Daily Living, including medication management, meal preparation, and money management.
• Significant Change: A major decline or improvement in the resident’s status that will not resolve itself without intervention.

Operative Clauses

1. Cognitive Status:

   • Alert and Oriented
   • Mild Cognitive Impairment
   • Moderate Dementia/Memory Loss
   • Severe Cognitive Impairment
   • Notes: [__________]

2. Activities of Daily Living (ADL) Support Needs:

   • Indicate level of assistance required: (I) Independent, (S) Supervision, (A) Assistance, (D) Dependent.
   • Bathing: [ ] | Dressing: [ ] | Grooming: [ ] | Toileting: [ ] | Transferring: [ ] | Eating: [ ]

3. Mobility and Fall Risk:

   • Mobility Status: [ ] Ambulatory [ ] Uses Cane [ ] Uses Walker [ ] Wheelchair Dependent
   • Fall History (Last 6 Months): [ ] Yes [ ] No
   • Fall Risk Assessment Score: [__________]

4. Medication Management:

   • The resident is: [ ] Capable of self-administration [ ] Requires staff assistance/reminders [ ] Requires full administration by staff.
   • Pharmacy Name: [__________]

5. Behavioral Health and Social Needs:

   • Potential for wandering: [ ] Yes [ ] No
   • History of aggressive behavior: [ ] Yes [ ] No
   • Preferred social activities: [__________]

6. Medical Equipment and Specialized Care:

   • Oxygen: [ ] Yes [ ] No
   • Incontinence Care: [ ] Yes [ ] No
   • Special Diet: [__________]

Signature and Acknowledgment

By signing below, the assessor confirms that the information provided above is accurate to the best of their professional knowledge, and the resident’s needs are within the scope of services provided by this facility.

Assessor Signature: __________ Printed Name: [] Title: [] Date: [__________]

Resident/Representative Signature: __________ Date: [__________]

Disclaimer: This document is a general framework intended for administrative and clinical record-keeping. It does not constitute legal or medical advice. Please consult with qualified legal counsel to ensure this form complies with all local, state, and federal regulations governing assisted living facilities in your jurisdiction.