<p> * Initial assessments and Annual re-assessments must be completed thoroughly. Assessments completed because of a change in condition will be addressed only in areas of change.*</p><p>RESIDENT ASSESSMENT Name Date of Birth Date of Assessment</p><p>Primary Diagnosis Secondary Diagnosis</p><p>Reason for Assessment History Received From:  Initial  Annual  Noteworthy Change LIVING ARRANGEMENTS (this section to be completed on initial assessment only) Current Home Conditions Safety Hygiene  Clean  Unclean  Good  Fair  Poor  Good  Fair  Poor</p><p>Comments: ______</p><p>Temperature Pulse BP Respiration Height (ft/in) Weight (lb)</p><p>ALLERGIES Medications Foods</p><p>Pollens Other</p><p>Comments: ______HABITS Do you smoke? Amount Number of Years Last Usage  Yes  No    Do you drink alcohol? Amount Number of Years Last Usage  Yes  No    Do you use recreational drugs? Type(s) Number of Years Last Usage  Yes  No    If a current smoker, evaluate ability to smoke independently. Any special safety provisions required?</p><p>HOBBIES/INTERESTS: </p><p>Hobbies/activities enjoyed: Community Contacts:</p><p>CULTURAL/SPIRITUAL</p><p>Religious/Cultural Affiliation Are there any religious, cultural, or ethnic practices that will affect your care?</p><p>MEDICAL HISTORY:</p><p>Page 1 of 8 Resident Assessment</p><p>SURGICAL HISTORY</p><p>SURGERY DATE SURGERY DATE</p><p>1. 6.</p><p>2. 7.</p><p>3. 8.</p><p>4. 9.</p><p>5. 10. MEDICATIONS</p><p>Who is responsible to purchase medications? Who is responsible to store medications? Who is responsible to administer medications? Primary Pharmacy: Phone Number:</p><p>MEDICATION DOSAG ROUTE FREQUENCY DATE OF RX PHYSICIAN</p><p>Any over-the-counter medications commonly used, and reasons for use: </p><p>Have there been any recent changes in medications? ......  Yes  No If yes, explain:</p><p>COMFORT Pain/Discomfort Intensity (1-10) Location What relieves your pain?  Yes  No How do others recognize that you are in pain? SLEEPING PATTERNS: </p><p>Page 2 of 8 Resident Assessment</p><p>COMMUNICATION Speech Education Level Primary Language Hearing Vision</p><p>Modes of expression:</p><p>Able to make self understood?  Yes  No Explain: Able to understand others?  Yes  No Explain: Comments: </p><p>ABILITIES: Activities of Daily Living ACTIVITY Independent Needs Dependent RECOMMENDATIONS COMMENTS Assistance Eating Ambulation Transfer Grooming Oral Hygiene Toileting Dressing Bathing Food Preparation Medications Manage Finances Healthcare Visits DAILY ROUTINES: typical 6 AM 6 PM 7 AM 7 PM 8 AM 8 PM 9 AM 9 PM 10 AM 10 PM 11 AM 11 PM 12PM 12 AM 1 PM 1 AM 2 PM 2 AM 3 PM 3 AM 4 PM 4 AM 5 PM 5 AM ORTHOPEDIC Equipment Used/Comments: </p><p>Page 3 of 8 Resident Assessment</p><p>NEUROLOGICAL Mental Status  Oriented  Alert  Cooperative  Agitated  Anxious  Confused  Restless Confused/Disoriented To: Level of Consciousness:</p><p>Motor Movement Right Arm: Left Arm: Right Leg: Left Leg: Paralysis Location Syncope Vertigo Tremors  Yes  No   Yes  No  Yes  No  Yes  No Seizures Type Duration Last Seizure  Yes  No    Comments: </p><p>RESPIRATORY Airway Breathing Sounds Right: Left: Oxygen Therapy Type Liters per Minute: Assistance Required:  Yes  No    Yes  No Comments: </p><p>CARDIOVASCULAR Dizziness Shortness of Breath Edema Cyanosis  Yes  No  Yes  No  Yes  No  Yes  No Comments: </p><p>GASTROINTESTINAL Diet Appetite # Meals/day # Snacks/day Dietary Supplements Recent Wt loss/gain</p><p>Mouth Problems If yes, explain:  Yes  No  Swallowing Difficulties: If yes, explain:  Yes  No  Dentures Teeth Problems If yes, explain:  Upper  Lower  None  Yes  No </p><p>Page 4 of 8 Resident Assessment</p><p>Bowel Schedule/Patterns Bowel Management Program Specify:  Yes  No  Check all that apply: Use of Incontinence Products? Specify  Incontinent  Laxative use  Constipation  Diarrhea  Yes  No  Comments/preferences: </p><p>GENITOURINARY Bladder  Dribbling  Incontinent  Frequency  Burning  Nocturia  UTI  Hematuria  Stones  Stoma  Difficulty  Retention  Distention Starting Stream Onset of Symptoms</p><p>Catheter Type Size Last Changed  Yes  No    Dialysis Frequency Location of Dialysis Service/Phone contact  Yes  No   Comments: </p><p>SKIN Color Temperature Turgor</p><p>PROBLEMS LOCATION(S) PROBLEMS LOCATION(S) Edema Ecchymosis Dry Skin Abrasion Flaky Skin Laceration Rash Pressure Ulcer Lesion Wound Scars Dressings Burns Stoma</p><p>Page 5 of 8 Resident Assessment</p><p>Colostomy Wounds/ Location Length Width Depth Frequency  Bag  Decubitus      Dressing:  List any previous or potential skin conditions: </p><p>Comments: </p><p>SAFETY ISSUES Does the participant have the ability (physical, cognitive, etc) to leave the boarding home without supervision? ......  Yes  No </p><p>Explain: </p><p>Can participant access emergency response without assistance? ......  Yes  No </p><p>Explain: </p><p>Can participant access emergency exits independently? ......  Yes  No </p><p>Explain: </p><p>List any additional safety needs:</p><p>DECISION-MAKING CAPABILITIES</p><p>Can make own decisions: Alternate Decision Maker/Contact #: Advance Directives in place, if any:</p><p> Yes  No Scope of decision-making abilities:</p><p>Page 6 of 8 Resident Assessment</p><p>ADDITIONAL ASSESSMENT TOOLS USED (please see attached forms, as necessary)</p><p>Mental Health Dementia Other</p><p> Yes  No  Yes  No  Yes  No </p><p>NURSING NEEDS/DELEGATION ISSUES: </p><p>RECOMMENDATIONS: </p><p>Page 7 of 8 Resident Assessment</p><p>COMMENTS: </p><p>______</p><p>______Signature of prospective resident/resident Signature of responsible party/family</p><p>______Signature of Person Completing Assessment Credentials Date</p><p>______Signature of Registered Nurse, if applicable Date (Only if different from person completing Assessment)</p><p>Page 8 of 8</p>