3122 Form – Fill Out and Use This PDF

ALL SPACES MUST BE FILLED OUT
Resident’s Name: __________________________________________________________	Date of Exam: _________

Facility Name: ________________________________________ Date of Birth:__________ Sex:_______

Present Home Address:____________________________________________________________________________

	Street		City		State	Zip
	Reason for evaluation:  Pre-Admission  12 month  Acute change in condition				 Other :_____________________
			MEDICAL REVIEW FINDINGS
	Vital Signs: BP: _______ Pulse:_____	Resp: _______ T: _______ Height: _____ft _____in. Weight: _______

Primary Diagnosis(s): _____________________________________________________________________________

________________________________________________________________________________________________________

Secondary Diagnosis(s): ___________________________________________________________________________

_______________________________________________________________________________________________

Allergies:  None or list Known Allergies: ___________________________________________________________

Diet:  Regular	 No Added Salt  No Concentrated Sweets  Other: ________________________
Immunizations:	 Influenza (Date_____________)	 Pneumococcal Vaccine (Date_____________)

TB SCREENING (performed within 30 days prior to initial admission unless medically contraindicated)

Test is contraindicated	Test:  TST1  TST2 TB Blood Test (Type)____________ Date______ Result_______
TST1: Date placed______	Date Read______ mm______ TST2: Date placed______ Date Read______ mm______

Based on my findings and on my knowledge of this patient, I find that the patient _______ IS _______ IS NOT exhibiting signs

or symptoms suggestive of communicable disease that could be transmitted through casual contact.

CONTINENCE

Bladder: Yes  No  If no, is incontinence managed? Yes  No 

Bowel: Yes  No  If no, is incontinence managed? Yes  No 

If no, recommendations for management:__________________________________________________________________

LABORATORY SERVICES: None
Lab Test	Reason/Frequency	Lab Test	Reason/Frequency
________________	_______________________________	________________	_________________________
__________________	__________________________________	_________________	____________________________
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Patient/Resident Name: ______________________________________________ Date: __________________________

ACTIVITIES OF DAILY LIVING (ADL’s)

Activity Restrictions: No  Yes  (describe):____________________________________________________________

Dependent on Medical Equipment: No  Yes  (describe):_________________________________________________

Level and frequency of assistance required/needed by the resident of another person to perform the following:

1.	Ambulate:	Independent 	Intermittent	 Continual 
2.	Transfer:	Independent 	Intermittent	 Continual 
3.	Feeding:	Independent 	Intermittent	 Continual 
4.	Manage Medical Equipment:		Manages Independently  Cannot Manage Independently 

ADDITIONAL SERVICES IF INDICATED BY RESIDENT NEED:

Pertinent medical/mental findings requiring follow-up by facility (e.g. skin conditions/acute or chronic pain issues) or any additional recommendations for follow-up: None  or if yes, describe_____________________________

____________________________________________________________________________________________________________

Therapies:  None Yes (specify):  Physical Therapy Speech Therapy Occupational Therapy

Home Care:  None Yes (specify):__________________________ Other (Specify):__________________________

Is Palliative Care Appropriate/Recommended: No  If yes, describe services: ______________________________

COGNITIVE IMPAIRMENT/MEMORY LOSS (including dementia)

Does the patient have/show signs of dementia or other cognitive impairment?  No  Yes

If yes, do you recommended testing be performed?  No  If yes, referral to:______________________________________

If testing has already been performed, date/place of testing if known:______________________________________________

MENTAL HEALTH ASSESSMENT (non-dementia)
Does the patient have a history of or a current mental disability?	 No	 Yes
Has the patient ever been hospitalized for a mental health condition?	 No	 Yes

If yes, describe: ____________________________________________________________________________________________

Based on your examination, would you recommend the patient seek a mental health evaluation? (If yes, provide referral) No Yes Describe: ______________________________________________________________________________

MEDICATIONS

Pursuant to NYCRR Title 18 487.7(f)(2), the patient is NOT capable of self-administration of medication if he/she needs assistance to properly carry out ONE OR MORE of the following tasks:

Correctly read the label on a medication container  Correctly follow instructions as the route, time dosage and frequency

 Correctly ingest, inject or apply the medication	 Measure or prepare medications, including mixing, shaking and filling
 Open the container	syringes
 Safely store the medication	 Correctly interpret the label
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Patient/Resident Name: ________________________________________________

Date: ___________________

Resident will receive assistance with all medications unless physician indicates that resident is capable of self- administration.

1. Does the patient/resident require assistance with medications (see criteria on page 2)? Yes  No 

2.List all prescription, OTC medications, supplements and vitamins. Attach additional sheets if necessary or attach current discharge note, signed by the physician, listing ALL medications.

STATEMENT OF PURPOSE

Adult Homes (AH), Enriched Housing Programs (EHP), Residences for Adults (RFA), Assisted Living Residences (ALR), Enhanced Assisted Living Residences (EALR) and Special Needs Assisted Living Residences (SNALR):

•provide 24-hour residential care for dependent adults

•are not medical facilities

•are not appropriate for persons in need of constant medical care and medical supervision and these persons should not be admitted or retained in these settings because the facility lacks the staff and expertise to provide needed services.

•Persons who, by reason of age and/or physical and/or mental limitations who are in need of assistance with activities of daily living, can be cared for in adult residential care settings listed above, or if applicable, an EALR or SNALR.

PHYSICIAN CERTIFICATION

I certify that I have physically examined this patient and have accurately described the individual’s medical condition, medication regimen and need for skilled and/or personal care services. Based on this examination and my knowledge of the patient, this individual (see Statement of Purpose):

Yes	 No	Is mentally suited for care in an Adult Home/Enriched Housing Program/Assisted Living Residence/ Enhanced
		Assisted Living Residence (EALR)/Special Needs Assisted Living Residence (SNALR).
Yes	 No	Is medically suited for care in an Adult Home or Enriched Housing Program/Assisted Living Residence / Enhanced
		Assisted Living Residence (EALR)/Special Needs Assisted Living Residence (SNALR).
Yes	 No	Is not in need of continual acute or long term medical or nursing care, including 24-hour skilled nursing
		care or supervision, which would require placement in a hospital or nursing home.

Name/Title of individual completing form:_____________________________________________ Date:____________

Physician Signature: ________________________________________________	Date _______________________
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