AHCA Form 3110 1023 - Resident Health Assessment for Adult Family-Care Homes

Resident Health Assessment for Adult Family-Care Homes (AFCH): enter the Name, D.O.B., Known Allergies, Height and Weight.

Under Health Assessment, fill in Medical history and diagnoses, Physical or sensory limitations, Cognitive or behavioral status, Nursing/treatment/therapy service requirements and Special precautions.

Under A, check the appropriate areas for the extent to which the individual needs supervision or assistance with Ambulation, Bathing, Dressing, Toileting, Eating, Grooming and Transferring. Use Comments if additional page is necessary.

Under B, check the appropriate box for the extent to which the individual is able to perform other self-care tasks such as preparing meals, shopping, or making phone calls: Independent, Needs Supervision, Needs Assistance or Needs Total Assistance.

Under C, check the appropriate box for the extent to which the individual needs general oversight such as observing the individual's well-being and whereabouts and reminding the individual of important tasks: Independent, Weekly Oversight, Daily Oversight or Other. For Other, please describe.

Under D, check the appropriate box if the individual requires special diet instructions: Regular, Diabetic Diet, No Added Salt, Low Fat, Low Cholesterol or Other. For Other, please describe. Under E, list all current medications prescribed (additional pages may be attached).

Enter the Medication, Dosage, Directions for Use and Route.

Does the individual need help with medications? Mark YES or NO. If yes, please describe.

Under F, does the individual have any of the following conditions or requirements? Check the appropriate boxes YES or NO and add COMMENTS. First: a communicable disease which could be transmitted to other residents or staff?

Also under F, check YES or NO for: Bedridden, Any stage 2, 3, or 4 pressure sores, Pose a danger to self or others, Require 24-hour nursing care and Require 24-hour psychiatric supervision.

Under G, in your professional opinion, can this individual's needs be met in a residential facility (Adult Family Care Home) that is not a medical, nursing or psychiatric facility? Mark YES or NO. Use Comments if additional page is necessary.

Under H, in your professional opinion, based on this individual's medical profile, can this individual be left without supervision at the adult family care home for up to two hours per twenty-four (24) hour period without compromising his or her health, safety, security or well-being? Mark YES or NO.

Print the Name of Examiner, then enter the Medical License #, the Address of Examiner and the Telephone #.

Check the appropriate box for the Title of Examiner: MD, DO, ARNP or PA. Enter the Date of Examination.

Please return the completed form to the AFCH Provider Name, with the Address, Telephone # and Contact Person.