AHCA Form 3110 1023 PDF Details

AHCA Form 3110 1023 (AFCH-1110) is required by Florida's Agency for Health Care Administration for evaluating prospective residents of Adult Family-Care Homes. A licensed health professional completes this assessment to verify the AFCH can meet the resident's care needs before placement.

The form covers six key areas:

Related AHCA assessments: AHCA Form 1823 (ALF Resident Health Assessment), AHCA Form 3100-0008, and the Resident Assessment Form. For additional Florida care facility documents, see the Florida Health Care Surrogate Form.

QuestionAnswer
Form NameAHCA Form 3110 1023
Form TypeResident Health Assessment
StateFlorida
Issued ByFlorida Agency for Health Care Administration (AHCA)
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesAFCH-1110, ahca assessment, form 3110 1023, resident health assessment adult family care

Form Preview Example

RESIDENT HEALTH ASSESSMENT FOR ADULT FAMILY-CARE HOMES (AFCH)

NAME:

D.O.B.

 

KNOWN ALLERGIES:

HEIGHT:

WEIGHT:

 

 

 

 

HEALTH ASSESSMENT

 

Medical history and diagnoses:

Physical or sensory limitations:

Cognitive or behavioral status:

Nursing/treatment/therapy service requirements:

Special precautions:

ATo what extent does the individual need supervision or assistance with the following? Please check appropriate areas below. ↓

AMBULATION:

BATHING:

DRESSING:

TOILETING:

__Independent

__Independent

__Independent

__Independent

__Needs Supervision

__Needs Supervision

__Needs Supervision

__Needs Supervision

__Needs Assistance

__Needs Assistance

__Needs Assistance

__Needs Assistance

__Needs Total Help

__Needs Total Help

__Needs Total Help

__Incontinence

 

 

 

__Catheter Care

EATING:

GROOMING:

TRANSFERRING:

__Ostomy Assistance

__Independent

__Independent

__Independent

 

__Needs Supervision

__Needs Supervision

__Needs Supervision

 

__Needs Assistance

__Needs Assistance

__Needs Assistance

 

__Tube Feeding

__Needs Total Help

__Needs Total Help

 

Comments (Use additional page if necessary):

BTo what extent is the individual able to perform other self-care tasks such as preparing meals, shopping, or making phone calls? Please check the appropriate box below. ↓

Independent

 

Needs Supervision

Comments (Use additional page if necessary):

Needs Assistance

Needs Total Assistance

CTo what extent does the individual need general oversight such as observing the

individual’s well-being and whereabouts and reminding the individual of important tasks? Please check the appropriate box below. ↓

Independent

 

Weekly Oversight

Comments (Use additional page if necessary):

Daily Oversight

Other: Please describe below.

AHCA Form 3110-1023 (AFCH-1110) 01/08

1

Rule 58A-14.0061, F.A.C.

DDoes the individual require special diet instructions? Please check the appropriate box below. ↓

Regular

Diabetic Diet

No Added Salt

Low Fat

Low Cholesterol

Other: Please describe below:

EPlease list all current medications prescribed below (additional pages may be attached). ↓

 

MEDICATION

DOSAGE

DIRECTIONS FOR

ROUTE

 

 

 

USE

 

1.

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

Does the individual need help with medications? _____YES______NO. If yes, please describe:

FDoes the individual have any of the following conditions or requirements? Please check appropriate boxes below. ↓

YES NO COMMENTS

A communicable disease which could be transmitted to other residents or staff?

Bedridden?

Any stage 2, 3, or 4 pressure sores?

Pose a danger to self or others?

Require 24-hour nursing care?

Require 24-hour psychiatric supervision?

GIn 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? ______YES______NO Comments (Use additional page if necessary):

HIn 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?

______YES______NO Comments (Use additional page if necessary):

AHCA Form 3110-1023 (AFCH-1110) 01/08

2

Rule 58A-14.0061, F.A.C.

NAME OF EXAMINER (Please Print):

SIGNATURE OF EXAMINER:

MEDICAL LICENSE #:

ADDRESS OF EXAMINER:

TELEPHONE #:

TITLE OF EXAMINER (Please check the appropriate box:

DATE OF EXAMINATION:

MD

DO

ARNP

PA

PLEASE RETURN THE COMPLETED FORM TO: ↓

AFCH PROVIDER NAME:

ADDRESS:

TELEPHONE #:

CONTACT PERSON:

AHCA Form 3110-1023 (AFCH-1110) 01/08

3

Rule 58A-14.0061, F.A.C.

How to Edit Ahca Form 3110 1023 Online for Free

AHCA Form 3110 1023 can be completed online using the FormsPal PDF editor. The tool lets you fill in all required fields, add text, insert your signature, and save or print the completed document at no cost.

Step 1: First, access the pdf editor by pressing the "Get Form Button" in the top section of this webpage.

Step 2: Once you start the editor, you will find the document all set to be filled in. Apart from filling in various fields, it's also possible to perform other things with the Document, that is adding any textual content, changing the original textual content, adding graphics, placing your signature to the PDF, and much more.

Completing this document requires care for details. Make sure each field is done correctly.

1. Start completing your AHCA Form 3110 1023 with a group of major blank fields. Gather all of the required information and ensure not a single thing overlooked!

Writing section 1 of AHCA Form 3110 1023 resident health assessment

2. Right after completing this step, head on to the next step and fill in all required particulars in these fields - AMBULATION Independent Needs, BATHING Independent Needs, TOILETING Independent Needs, DRESSING Independent Needs, B To what extent is the individual, meals shopping or making phone, Independent, Needs Supervision, Comments Use additional page if, Needs Assistance, Needs Total Assistance, and C To what extent does the.

AMBULATION Independent Needs, TOILETING Independent Needs, and BATHING Independent Needs in AHCA Form 3110 1023

People often make errors when filling out AMBULATION Independent Needs in this section. Make sure you review everything you type in right here.

3. The following section focuses on C To what extent does the, Independent, Weekly Oversight, Daily Oversight, Other Please describe below, Comments Use additional page if, and AHCA Form AFCH Rule A FAC - fill in all these blanks.

AHCA Form 3110 1023 writing process explained (stage 3)

4. Completing below, Regular, Diabetic, No Added, Diet, Salt, Low Fat, Low Cholesterol, Other Please describe, below, E Please list all current, MEDICATION, DOSAGE, DIRECTIONS FOR, and ROUTE is essential in this fourth step - be certain to take the time and take a close look at every field!

AHCA Form 3110 1023 writing process outlined (step 4)

5. The final stage to finish this PDF form is pivotal. Make certain to fill in the necessary blanks, like A communicable disease which could, YES NO COMMENTS, In your professional opinion can, and In your professional opinion based, before using the file. Otherwise, it may result in an incomplete and possibly invalid document!

Step 5 in filling out AHCA Form 3110 1023 resident health assessment

Step 3: Immediately after double-checking the form fields, hit "Done" and you are good to go! After creating a free account, it will be possible to download AHCA Form 3110 1023 or send it via email. The file will also be accessible via your personal cabinet with all modifications. We don't share or sell any information provided when filling out documents at our site.

Also useful: AHCA Form 1823 (ALF resident assessment), AHCA Form 3020, and the Nursing Home Form.

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