DOEA 701B Form PDF Details

In the realm of elder care and support within the state of Florida, the DOEA 701B Comprehensive Assessment Form emerges as a critical document, articulated by the Florida Department of Elder Affairs. At the heart of this form lies a meticulous gathering of demographic, health, sensory, communication, and daily living activity data, aimed at crafting a nuanced understanding of the elderly's needs. Embarking with sections that traverse through basic identification including social security and Medicaid numbers, it progresses to encapsulate details about the individual's living situation, caregiver dynamics, and their environment. A notable emphasis is placed on assessing the individual's physical health, cognitive capabilities including memory function, as well as sensory and communication abilities, to illuminate any assistance or devices that may be requisite. Moreover, the form inquires into activities of daily living (ADLs), gauging the level of dependence in tasks such as bathing, dressing, and mobility. This thorough evaluation not only underscores the initial, annual, or transitional situations that necessitate the assessment but also carves pathways for tailored care plans, ensuring the elderly receive apt support and resources indispensable for maintaining their dignity and quality of life.

QuestionAnswer
Form NameDOEA 701B Form
Form Length19 pages
Fillable?Yes
Fillable fields1316
Avg. time to fill out38 min 17 sec
Other names701b, florida 701b training, 701b certification, 701b assessment

Form Preview Example

 

 

Florida Department of Elder Affairs

 

 

701B Comprehensive Assessment

 

 

Rule: 58-A-1.010, F.A.C.

 

 

 

 

 

 

Provider ID:

 

 

Provider

 

Assessor/CM ID:

 

 

Assessor/Case

 

 

 

 

 

 

 

Manager (CM) Name:

 

 

Signature:

 

 

A. DEMOGRAPHIC SECTION

 

 

 

 

1.ASSESSOR/CM: What is the purpose of this assessment?

 

 

Initial Annual Health Living situation

Caregiver Environment

Income

 

 

2.

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Name: a. First:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Middle initial:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Last:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Medicaid number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Phone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Date of birth (mm/dd/yyyy):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Sex:

 

 

Male

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Race (Mark all that apply):

 

 

White

 

Black/African American

 

Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian/Alaska Native

 

Native Hawaiian/Pacific Islander

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

9.

Ethnicity:

 

 

Hispanic/Latino

 

Other

 

 

 

 

 

 

 

 

 

10.

Primary language:

 

 

English

 

Spanish

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Does client have limited ability reading, writing, speaking, or understanding English? No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Marital status:

 

 

Married

 

 

Partnered

Single

Separated

 

Divorced

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.ASSESSOR/CM: Current Physical Location Address (If type is a facility, enter facility name.)

a. Street:

 

 

b. City:

 

 

 

 

 

 

 

 

 

 

c. ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Type:

 

 

 

Private residence

 

Assisted living facility (ALF)

 

Nursing facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital

 

Adult day care

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Home Address (If different from current physical location)

 

 

 

 

 

 

 

 

 

 

 

a. Street:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. City:

 

 

 

 

 

 

 

 

 

 

 

 

 

c. ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Is client’s home address public housing? No Yes

 

 

 

 

 

Mailing Address (If different from current physical location)

 

 

 

 

 

16.

 

 

 

 

 

 

 

 

 

 

 

a. Street:

 

 

 

 

 

 

 

b. City:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. State:

 

 

 

 

 

 

 

 

d. ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

A. DEMOGRAPHIC SECTION, CONTINUED

 

17.

ASSESSOR/CM: Assessment date: (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

ASSESSOR/CM: Assessment site:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

ALF Nursing facility Hospital

Adult day care

Other

 

 

 

 

 

 

19.

ASSESSOR/CM: Referral date: (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

ASSESSOR/CM: Referral source:

 

 

 

Self/Family

 

Nursing facility

 

Case management agency

 

 

 

 

 

 

CARES

Aging out

 

 

 

 

Hospital

 

Department of Children and Families

 

Other

 

 

 

 

 

 

APS: Select level of APS risk

:

 

 

High

 

Intermediate

 

 

Low

 

 

 

 

 

 

21.

ASSESSOR/CM: Transitioning out of a nursing facility?

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

22.

ASSESSOR/CM: Imminent risk of nursing home placement?

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.

Do you need outside assistance to evacuate?

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

24.

Are you enrolled on a special needs registry?

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

Is there a primary caregiver?

 

 

 

 

 

 

 

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

26.

Living situation:

With primary caregiver

With other caregiver

 

With other

 

Alone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.

Individual monthly income:

$

 

 

 

 

 

 

 

Refused

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refused

 

 

N/A

 

 

 

 

 

 

 

28.

Couple monthly income:

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

Estimated total individual assets:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$0 to $2,000

 

 

 

$2,001 to $5,000

 

$5,001 or more

 

Refused

 

 

 

 

 

 

 

30.

Estimated total couple assets:

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$0 to $3,000

 

 

 

 

$3,001 to $6,000

 

 

$6,001 or more

 

Refused

 

N/A

 

 

 

 

31.

Are you receiving S/NAP (food stamps)?

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

32.

Do you need other assistance for food?

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33. ASSESSOR/CM: Is someone besides the client providing answers to questions?

No (Skip to 34) Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Name

:

 

 

 

b.Relationship:

 

 

 

 

34. Besides your own children, how many children under age 19 do you live with and provide care for?

 

 

 

(if zero, skip to 35)

 

 

 

 

 

 

#

 

 

a. How many are grandchildren?

 

 

 

 

 

 

 

 

 

 

 

#

 

 

Name(s):

 

 

 

 

b. How many are other related children?

#

 

 

Name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. How many are other non-related children?

 

 

 

 

 

 

 

 

 

 

 

#

 

 

Name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35. How many disabled adults age 19 to 59 do you live with and provide care for? (if zero, skip to 36)

#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. How many are grandchildren?

 

 

 

 

 

 

 

 

 

 

 

#

 

 

Name(s):

 

 

 

 

b. How many are other relatives?

#

 

 

Name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. How many are other non-relatives?

 

 

 

 

 

 

 

 

 

 

 

#

 

 

Name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes & Summary:

2DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

B. MEMORY SECTION

36. Has a doctor or other health care professional told you that you suffer from memory loss, cognitive

impairment, any type of dementia, or Alzheimer’s disease?

No

Yes

 

 

 

 

 

37.ASSESSOR/CM: If the client is not answering questions, skip to Question 47 and check:

38.“I am going to say three words for you to remember. Please repeat the words after I have said them. The

words are: sock (something to wear), blue (a color), and bed (a piece of furniture). Now you tell me the

three words.” ASSESSOR/CM: Select the number of words correctly repeated after the first attempt:

 

 

Sock Blue Bed

Total number of correct words: None

 

One Two Three

 

 

 

 

 

 

 

 

 

 

 

 

 

“Thank you. I will ask you to repeat these to me again later.”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

39.

Please tell me what year it is:

 

 

Correct

Missed by one year

 

Missed by two to five years

 

 

 

 

 

 

Missed by five or more years

 

No answer

 

 

 

 

 

 

 

 

 

 

 

 

40.

Please tell me what month it is:

 

 

Correct

Missed by one month

 

Missed by two to five months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Missed by five or more months

 

No answer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

41.

Please tell me what day (of the week) it is:

Correct Incorrect

 

No answer

 

 

42.

“Let’s go back to an earlier question. What were those words I asked you to repeat back to me?”

 

 

 

Sock Blue Bed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

43.ASSESSOR/CM: Number of words correctly recalled without prompting: None One Two Three

 

44.

Have any friends or family members expressed concern about your memory?

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

45.

Have you become concerned about your memory or had problems

No (Skip to 47)

Yes

 

 

remembering important things?

 

 

 

 

 

 

46.

How often do you have problems remembering things?

 

 

 

 

 

 

 

Always Often Sometimes Rarely Don’t know

 

 

 

47.

ASSESSOR/CM: In your opinion, are cognitive problems present?

No

Yes

Don’t know

Notes & Summary:

3DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

C. GENERAL HEALTH, SENSORY & COMMUNICATION SECTION

 

 

 

 

 

 

 

Excellent

 

Very Good

Good

Fair

 

Poor

 

 

 

 

48.

How would you rate your overall health at this time?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

49.

Compared to a year ago, how would you rate your health?

 

 

 

 

 

 

 

 

 

 

 

 

Much better

Better

About the same

 

Worse

Much worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

50.

How often do you change or limit your activities out of fear of falling?

 

 

 

 

 

 

 

 

 

 

Never

Occasionally

Often

 

All of the time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

51.

How many times have you fallen in the last six months? #

 

 

 

 

 

 

 

 

 

 

52.

How often are there things you want to do but cannot because of physical problems?

 

 

 

 

 

 

Never

Occasionally

Often

 

All of the time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

53. When you need medical care, how often do you get it?

Always Most of the time Rarely Only in an emergency Never 54. When you need transportation to medical care, how often do you get it?

 

 

 

Always

Most of the time

Rarely

 

Only in an emergency

 

Never

 

 

 

 

 

 

 

55.

Do you drive a car or other motor vehicle?

No

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

56.

How often do finances/insurance allow you to obtain health care and medications when you need them?

 

 

 

 

 

Always

Most of the time

Rarely

 

Only in an emergency

 

Never

 

 

 

57.

Have you visited the emergency room (ER) or been admitted to the hospital within the last year?

 

 

 

 

No Yes:

How many times? ER#

 

 

Hospital #

 

 

 

 

 

 

 

 

 

 

 

 

 

58.

In the last year were you in a nursing or rehabilitation facility?

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

59.

Are you usually able to climb two or three stair steps?

 

No

 

Yes Don’t know

 

 

60.

ASSESSOR/CM: Are there any stairs within the dwelling or leading into/out of the dwelling? No Yes

 

 

 

61. Are you usually able to carry a full glass of water across a room without spilling it?

No

Yes Dont know

 

 

62. Has a doctor told you that you currently have vision problems?

 

No

 

Yes

 

Blind (If blind, skip to 63)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Have you had an eye exam in the past year?

 

 

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

b. Do you bump into objects (people, doorways) because you don’t see them?

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Is your vision getting worse than it was last year?

No In one eye

 

Slightly worse Much worse

 

 

63. Has a doctor told you that you currently have hearing problems?

 

No

 

Yes

Deaf (If deaf, skip to 64)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Have you had a hearing exam in the past year?

 

 

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

b. Can you understand words clearly over the telephone?

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Is your hearing worse than it was last year?

No In one ear

 

Slightly worse Much worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

64.

ASSESSOR/CM: Does client rely on writing, gestures, or signs to communicate?

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

65.

ASSESSOR/CM: Are the client’s words formed properly, not slurred or clipped?

 

No

 

 

Yes

 

 

66.

ASSESSOR/CM: Are any sensory aids or assistive devices currently used?

 

 

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, please list the type(s) used:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

67.

ASSESSOR/CM: Is there an unmet need for a sensory aid or assistive device?

 

No

 

 

Yes

 

If yes, please list the type(s) needed:

4DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

D. ACTIVITIES OF DAILY LIVING SECTION

68. How much assistance do you need with the following tasks?

 

 

 

No

 

Uses

 

Needs

Needs

 

Needs total

 

 

Task

 

assistance

 

assistive

 

supervision

assistance (but

 

assistance

 

 

 

 

needed

 

device

 

or prompt

not total help)

 

(cannot do at all)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Bathing

 

 

 

 

 

 

 

 

 

b. Dressing

 

 

 

 

 

 

c. Eating

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Using the bathroom

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Transferring

 

 

 

 

 

 

 

f. Walking/Mobility

 

 

 

 

 

69. ASSESSOR/CM: Is there an unmet need for an ADL assistive device?

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, type(s) needed:

70. How much assistance do you have with the following tasks?

 

 

 

 

 

 

 

 

 

Has

 

 

 

 

 

 

Task

 

No

 

 

 

assistance

 

 

 

 

 

 

 

assistance

 

Always has

most of the

 

Rarely has

 

Never has

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

needed

 

assistance

 

time

 

assistance

 

assistance

 

 

 

a. Bathing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Dressing

 

 

 

 

 

 

 

 

c. Eating

 

 

 

 

 

 

 

 

 

d. Using the bathroom

 

 

 

 

 

 

 

 

e. Transferring

 

 

 

 

 

 

 

 

 

f. Walking/Mobility

 

 

 

 

 

 

Notes & Summary:

5DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

E. INSTRUMENTAL ACTIVITIES OF DAILY LIVING SECTION

71. How much assistance do you need with the following tasks?

 

 

 

 

 

 

No

 

Uses

 

Needs

 

Needs

 

Needs total

 

 

 

Task

 

assistance

 

assistive

 

supervision

 

assistance (but

 

assistance

 

 

 

 

 

 

 

needed

 

device

 

or prompt

 

not total help)

(cannot do at all)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Heavy chores

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Light housekeeping

 

 

 

 

 

 

 

 

 

c. Using the telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Managing money

 

 

 

 

 

 

 

 

 

e. Preparing meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Shopping

 

 

 

 

 

 

 

 

 

g. Managing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Using transportation

 

 

 

 

 

 

 

72. ASSESSOR/CM: Is there an unmet need for an IADL assistive device?

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, type(s) needed:

73. How much assistance do you have with the following tasks?

 

 

 

 

 

 

 

 

 

Has

 

 

 

 

 

 

Task

 

No

 

 

 

assistance

 

 

 

 

 

 

assistance Always has

 

most of the

 

Rarely has

 

Never has

 

 

 

 

 

 

 

 

 

 

 

 

 

 

needed

 

assistance

 

time

 

assistance

 

assistance

 

 

 

a. Heavy chores

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Light housekeeping

 

 

 

 

 

 

 

 

c. Using the telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Managing money

 

 

 

 

 

 

 

 

e. Preparing meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Shopping

 

 

 

 

 

 

 

 

g. Managing medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Using transportation

 

 

 

 

 

 

Notes & Summary:

6DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

F. HEALTH CONDITIONS & THERAPIES SECTION

74.Have you been told by a physician that you have any of the following health conditions?

ASSESSOR/CM: Indicate whether a problem occurred in the past by marking the first box and when a problem is current by marking the second box. Mark all that apply.

 

 

 

Past

Current

 

Health Conditions

 

 

 

 

Acid reflux/GERD

 

 

 

 

 

 

 

Allergies, list:

 

 

 

Amputation, site:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anemia

 

 

Severe Moderate

Mild

 

 

 

Arthritis, type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bed sore(s) (Decubitus), location:

 

 

 

Blood pressure

 

 

High

 

 

Low

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Broken bones/fractures, location:

 

 

 

Cancer, site:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chlamydia

 

 

 

 

 

 

 

 

 

 

 

 

Cholesterol

 

 

High

 

Low

 

 

 

 

 

 

 

 

 

 

Dehydration

 

 

 

 

 

 

 

 

 

 

 

Diabetes

 

 

IDDM

 

NIDDM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dizziness

 

 

Constant

 

Frequent

Occasional

Rare

 

 

 

Fibromyalgia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gallbladder

 

 

Removal

 

Problems

 

 

 

 

 

Gonorrhea

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart problems

 

 

Pacemaker

 

CHF

MI

Other

 

 

 

Head, brain, or spinal cord trauma

 

 

 

 

 

 

 

 

 

 

 

 

 

Herpes

 

 

 

 

 

 

 

 

 

 

 

Human Immunodeficiency Virus (HIV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Human Papilloma Virus (HPV)/Genital warts

 

 

 

 

 

 

Constant

 

Frequent

 

 

Occasional

 

 

Rare

 

 

 

 

Incontinence, bladder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incontinence, bowel

Constant

Frequent

 

Occasional

 

Rare

 

 

 

 

Kidney problems or renal disease

 

End stage?

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

Liver problems

Cirrhosis

 

Hepatitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lung problems

 

 

Emphysema

 

Asthma

 

 

Pneumonia

 

 

COPD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lupus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Multiple Sclerosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Muscular Dystrophy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Osteoporosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parkinson’s disease

 

 

 

 

 

 

 

 

 

 

 

Paralysis

 

 

Full

 

Partial

 

Local, site:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Seizure disorder, type & frequency:

7DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

F. HEALTH CONDITIONS & THERAPIES SECTION, CONTINUED

 

Past

 

Current

 

Health Conditions

 

 

 

 

Shingles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stroke/CVA

 

 

 

 

Syphilis

 

 

 

 

 

 

 

 

 

Thyroid problems/Graves/Myxedema Hyper Hypo

 

 

 

 

Tumor(s), site:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ulcer(s), site:

 

 

 

 

 

 

 

 

 

 

 

 

Urinary Tract Infection (UTI)

 

 

 

 

 

 

 

 

Other:

 

75. Provide information on the frequency of current therapies or specialty care:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Several

 

 

 

 

Several

 

 

 

 

 

 

 

 

 

 

 

N/A or

 

 

 

 

 

 

times

 

 

 

 

times

 

 

 

 

Treatment type:

 

None

Monthly

 

Weekly

 

a week

 

Daily

 

a day

 

 

 

 

a. Bladder/bowel treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Catheter, type:

 

 

 

 

 

 

 

 

 

 

 

c. Dialysis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Insulin assistance

 

 

 

 

 

 

 

 

 

 

e. IV Fluids/IV Medications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f.

Occupational therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Ostomy, site:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Oxygen

 

 

 

 

 

 

 

 

 

 

 

i.

Physical therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j.

Radiation/Chemotherapy

 

 

 

 

 

 

 

 

 

 

k. Respiratory therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l.

Skilled nursing

 

 

 

 

 

 

 

 

 

 

m. Speech therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

n. Suctioning

 

 

 

 

 

 

 

 

 

 

o. Tube feeding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

p. Wound care/Lesion irrigation

 

 

 

 

 

 

 

 

 

 

q. Other therapy, type:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes & Summary:

8DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

G. MENTAL HEALTH SECTION

ASSESSOR/CM: If the client is not answering questions, skip to Question 81 and check:

 

 

 

Very satisfied

 

Satisfied

 

76. How satisfied are you with your overall quality of life?

 

 

 

 

 

 

 

 

 

Neither satisfied nor dissatisfied

 

Dissatisfied

 

Very dissatisfied

 

 

 

 

 

77. Thinking about how you were this time last year, how do you feel about the way things are now?

Much better

Better

About the same

Worse

Much worse

78. Over the past two weeks, how often have you been

 

 

More

 

 

 

than

Nearly

bothered by any of the following problems?

 

 

Not at

Several

half the

every

(Adapted from the Patient Health Questionnaire PHQ-9, © Pfizer)

all

days

days

day

 

 

 

a. Little interest or pleasure in doing things

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Feeling down, depressed, or hopeless

 

 

 

 

 

 

 

 

 

 

 

c. Trouble falling or staying asleep, or sleeping too much

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Feeling tired or having little energy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Poor appetite or overeating

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Feeling bad about yourself or that you are a failure or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

have let yourself or your family down

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Trouble concentrating on things, such as reading the

 

 

 

 

 

newspaper or watching television

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Moving or speaking so slowly that other people noticed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Or, the opposite, being so fidgety or restless that you

 

 

 

 

 

 

 

 

have been moving around a lot more than usual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i. Thoughts that you would be better off dead or of hurting

 

 

 

 

 

yourself in some way*

 

 

 

 

 

 

 

 

*Thoughts of suicide or self-injury, hallucinations, or aggressive behaviors are potentially serious problems that should be reported immediately to a supervisor, primary care physician, emergency care, law enforcement, and/or Adult Protective Services, as appropriate.

ASSESSOR/CM: If the client answered “Not at all” to a-i above, skip to Question 81.

79. How difficult have these problems made it for you in your daily life activities and interactions with others?

 

 

 

 

 

 

 

 

 

 

 

 

 

Not difficult at all

Somewhat difficult

Very difficult

 

Extremely difficult

 

 

 

 

 

 

 

 

 

 

 

 

 

 

80. Are you currently working with a professional to help with this condition?

 

No

 

Yes (Skip to 81)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Have you or do you plan to discuss these issues with a professional?

No

 

Yes (Skip to 81)

 

 

b. Do you talk about any of these issues with anyone else you know?

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

81. Have you been diagnosed with a mental condition or psychiatric disorder by a health professional?

No (Skip to 82)

Yes: List conditions:

9DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

G. MENTAL HEALTH SECTION, CONTINUED

82.ASSESSOR/CM: Indicate whether you noticed problem behaviors or any recurring problems have been reported to you by the client, caregiver, in-home worker, family, or staff, and note the frequency of occurrence in the last month. Provide details in the Notes & Summary section, below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Several

 

 

Problem behaviors

 

 

Not at all

 

Once

 

days

 

a. Forgetful or easily confused

 

 

 

 

 

b. Gets lost or wanders off

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Easily agitated or disruptive

 

 

 

 

 

d. Sexually inappropriate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Threatens or is verbally hostile*

 

 

 

 

f. Physically aggressive or violent*

 

 

 

 

 

 

 

 

 

g. Intentionally injures or harms him/herself*

 

 

 

 

 

h. Expresses suicidal feelings or plans*

 

 

 

 

 

 

 

 

 

 

 

 

 

i. Hallucinates, hears/sees things that are not

 

 

 

 

 

there*

 

 

 

 

 

 

 

 

 

 

 

 

j. Other:

 

 

 

 

 

 

 

 

 

 

 

 

More

Nearly

than half

every

the days

day

 

*Thoughts of suicide or self-injury, hallucinations, or aggressive behaviors are potentially serious problems that should be reported immediately to a supervisor, primary care physician, emergency care, law enforcement, and/or Adult Protective Services, as appropriate.

 

 

83. ASSESSOR/CM: Does client need supervision?

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes & Summary:

 

 

 

 

10DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

H. RESIDENTIAL LIVING ENVIRONMENT SECTION

84.ASSESSOR/CM: If information about the client’s residence is reported to you, without your observation, check here and all that apply below. If residence issues are directly observed by you, use the list

below to observe and check off the specific issue(s) with the potential for safety or accessibility problems.

Check all that apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Exterior issues(s):

Road

 

 

Driveway

 

Yard

 

Ramp

 

Windows

Roof

 

 

b. Interior issues(s):

Doors

 

 

Stairs

 

Floor

 

Walls

 

Ceiling

Lights

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Restroom issues(s):

 

 

 

Door

 

Handrails

 

Tub

 

Shower

Toilet

 

 

d. Utility issue(s):

 

 

 

 

 

Plumbing

 

Water

 

Electric

Gas

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Furniture issue(s):

 

 

 

 

 

Chair

 

Couch

 

Bed

Table

 

 

f. Telephone issue(s):

 

 

 

Broken

 

No phone

 

Disconnected/No service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Temperature issue(s):

 

 

 

Heat

 

Smoke detector

 

Air conditioning

 

 

h. Unsanitary condition(s):

 

 

Odors

 

Insects

 

 

 

Rodents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accumulating items or garbage

 

Floors or pathways

 

 

 

 

 

 

 

 

cluttered

i. Other hazards:

85. Is there a pet in your home or yard? No (Skip to 86) Yes

a. Please specify the type and size:

b. ASSESSOR/CM: Pet comments/concerns:

86.ASSESSOR/CM: Please rate the level of risk in the client’s residential living environment:

No/low apparent risk from current living conditions.

Minor risk (One or more aspects are substandard and should be addressed in the following year to

 

avoid potential injury.)

Moderate risk (Major aspects are substandard and must be addressed in the next few months to remain in home safely.)

High risk (Serious hazards are present. The client must change dwellings or immediate corrective action must be taken to correct the issues noted above.)

Notes & Summary:

11DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

I. NUTRITION SECTION

 

 

 

 

 

 

No

 

Yes

 

 

 

 

 

 

 

 

87.

Do you usually eat at least two meals a day?

 

 

 

 

 

 

 

 

 

 

88.

On a typical day, what types of food do you eat for:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

Breakfast:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Lunch:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Dinner:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

Snacks:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

89.

Do you eat alone most of the time?

No

Yes

 

 

 

 

90.

How many cups of water, juice, or other liquid do you drink daily? (If more than eight, skip to 91) #

 

a. Do you ever limit the amount of fluids you drink?

No (Skip to 91)

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

b.Why and when do you limit the fluids you intake?

91.On average, how many servings of fruits and vegetables do you eat every day? (One “serving” is one small piece of fruit or vegetable, about one-half cup of chopped fruit or vegetable, or

 

 

 

 

 

one-half cup of fruit or vegetable juice.)

 

 

 

 

 

 

 

 

 

#

 

 

 

 

 

92.

 

On average, how many servings of dairy products do you have every day? (One “serving” of

 

 

 

 

 

 

 

 

 

 

 

 

dairy is about a slice of cheese, a cup of yogurt, or a cup of milk or dairy substitute.)

#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

93.

 

Estimate your current height and weight:

Height:

 

 

ft.

inches

 

Weight:

 

 

 

 

lbs.

 

 

 

 

94.

 

Have you lost or gained weight in the last few months? Unsure (Skip to 95)

 

No (Skip to 95) Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.How much?

Less than five pounds

 

Five to ten pounds

 

Ten pounds or more

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.Was the weight loss/gain on purpose (i.e., dieting or trying to lose/gain weight)? No

 

 

 

 

Yes

 

 

 

95.

 

Are you on a special diet(s) for medical reasons?

 

No (Skip to 96)

 

Yes; check any/all:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Calorie supplement

Low fat/cholesterol

 

Low salt/sodium

 

Low sugar/carb

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

a. How long have you been on this diet?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Why are you on this diet?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

96.

 

Do you have any problems that make it hard for you to chew or swallow? No

Yes; check any/all:

 

 

 

 

 

Mouth/tooth/dentures

Pain or difficulty swallowing

Taste

Nausea

 

 

 

 

 

Saliva production

 

 

 

Other, describe:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

97.

What working appliances do you have for storing/preparing food? None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refrigerator Microwave

Toaster/Oven

Stove

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes & Summary:

12DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

J. MEDICATIONS & SUBSTANCE USE SECTION

98. Do you take three or more prescribed or over-the-counter medications a day? No

Yes

99.May I see all the medications you take, both regularly and those taken only as needed? Also, please show me all types of over-the-counter medications and any supplements that you regularly take.

ASSESSOR/CM: Check the original bottles in the medicine cabinet, nightstand, and refrigerator, as well as non-prescription drugs, over the counter drugs, sleep aids, herbal remedies, vitamins, and supplements.

 

 

 

Taken as

 

 

 

Prescribed

Prescribed

prescribed?

Administration

 

Medication name

dose

Frequency

Yes/No*

method

Prescriber name

If you have a printed list of meds managed by a facility, attach sheet. If there are more medications to record, use the Notes & Summary section or a blank sheet of paper to write the information.

100.*ASSESSOR/CM: Only ask when the client is not taking medications as indicated:

“Why do you take [name of medication] differently than prescribed?” and explain each below:

Medication and reason: Medication and reason:

Medication and reason: Medication and reason:

Medication and reason: Medication and reason:

Medication and reason: Medication and reason:

Medication and reason:

Medication and reason:

Medication and reason:

Medication and reason:

13DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

J. MEDICATIONS & SUBSTANCE USE SECTION, CONTINUED

101. Please list the doctors you usually go to for treatment and medications:

Physician name

 

Approx.

 

 

date of

 

Phone number

last visit

Reason for last visit:

If you have more than ten physicians to record, use the Notes & Summary section or a blank sheet of paper to write the information.

102.What pharmacies or drug stores do you use?

103.Are you able to tell the difference between your pills (i.e., colors, shapes, print)? No Yes N/A

 

104.

 

ASSESSOR/CM: Are the client’s medications managed by a facility/caregiver?

 

 

No

Yes

 

 

N/A

 

 

 

105.

 

ASSESSOR/CM: In your opinion, are the client’s medications managed properly?

No Yes

N/A

 

 

106.

 

ASSESSOR/CM: Should client have a new medication review by a doctor or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

Yes

 

 

N/A

 

 

 

 

 

 

 

pharmacist?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

107.

 

How many days in a typical week do you drink alcohol?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refused (Skip to 108)

None (Skip to 108)

 

One to two

 

Three to five Six to seven

 

 

 

 

 

 

a. On the days when you have some alcohol, about how many drinks do you usually have?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

One to two (Skip to 108)

 

 

Three to five

 

Six or more

 

 

 

 

 

 

 

 

 

 

 

 

b. About how many times in the last month have you had four or more drinks in a day?

 

 

 

 

 

 

 

 

 

 

 

 

 

None

One to two

 

Three to five

 

Six or more

 

 

 

 

 

 

 

 

1

08.

 

Have you used any form of tobacco in the last six months?

 

No (Skip to 109)

Yes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. What type(s)?

Chewing tobacco

 

Cigarettes

 

Cigars

 

Snuff

Other

 

 

 

 

 

 

b. About how many times do you use tobacco each day?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

One to three

Four to ten

Eleven or more

 

 

 

 

 

 

 

 

 

 

 

109.

 

Do you regularly use drugs other than those required for medical reasons (i.e., controlled substances or

 

 

 

 

 

 

“street drugs”)?

Refused (Skip to 110) No (Skip to 110)

 

Yes, what type(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. About how often do you use these?

 

Rarely

 

Less than twice a month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Less than once a week

Several times a week

 

Daily

 

 

Several times a day

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. How long have you been using that often?

 

Less than a year

 

One or more years

 

Notes & Summary:

14DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

K. SOCIAL RESOURCES SECTION

110.

If needed, is there someone (besides the primary caregiver) who could help you? No (Skip to 112) Yes

 

111.

Do I have your permission to contact this person, if you need help?

No (Skip to 112) Yes

a. Name: b. Relationship to client:

c. Phone:

 

 

Two to

Once

Several

Every

A few

 

About how often do you:

Once a

six times

a

times a

few

times

 

 

day

a week

week

month

months

a year

Never

112.Talk to friends, relatives, or others (by phone, computer, or other means)?

113.Spend time with someone who does not live with you?

114.Participate in activities outside the home that interest you?

      

      

      

L. CAREGIVER SECTION

ASSESSOR/CM: If client has no caregiver, stop the assessment here. If client has a caregiver, complete 115-136.

115.ASSESSOR/CM: HCE Caregiver? If yes, check

116.Caregiver full name: a. First:

b. Middle Initial:

c. Last:

117.Caregiver date of birth: (mm/dd/yyyy)

118.ASSESSOR/CM: Caregiver identification number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

19.

 

Caregiver sex:

 

Male

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

120.

 

Caregiver race (Mark all that apply):

 

White

 

Black/African American

 

Asian

 

 

American Indian/ Alaska Native

 

Native Hawaiian/ Pacific Islander

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

21.

 

Caregiver ethnicity:

 

 

 

 

 

 

Hispanic or Latino

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

122.

 

Caregiver primary language:

 

English

 

Spanish

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

23.

 

Caregiver relationship to client:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wife

 

Husband

 

 

 

 

 

Partner

 

 

 

Parent

 

 

 

Son/In-law

 

Daughter/In-law

 

Other relative

 

Other Non-relative

124.

 

Caregiver address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Street:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. City:

 

 

 

 

 

 

 

c. State:

 

 

d. ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

125.

 

Caregiver phone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

126.

 

Do you work outside the home?

 

No

 

Yes:

Full-time

 

Part-time

127.

 

Do you currently have anyone to assist you with providing care?

 

No (Skip to 129) Yes

15DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

L. CAREGIVER SECTION, CONTINUED

128. Do I have your permission to contact this person if for some reason you are unable to provide care for the

 

 

 

 

 

client?

No (Skip to 129)

Yes, please provide the name and relationship to client:

 

 

 

 

 

 

 

 

a. First name

:

 

 

 

b. Last name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Phone:

 

 

 

 

d. Relationship to client:

Wife Husband

Partner

 

 

 

 

 

 

Parent Son/In-law

Daughter/In-law

Other relative

Other Non-relative

 

 

129. How long have you been providing care for this client?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Less than six months

Six to twelve months

 

One to two years

 

Two or more years

 

 

 

 

 

 

 

 

 

130. How many hours per week do you currently spend providing care for the client?

 

#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

131. Do you need training or assistance in performing caregiving tasks?

No

Yes, please describe

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

132. How much of a mental or emotional strain is it on you to provide care for the client?

 

 

 

 

 

 

 

 

None

 

Some strain

A lot of strain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

133. Considering other aspects of your life,

 

 

No

 

 

Little

Some

 

Moderate

 

A lot of

 

 

 

 

 

 

 

please rate the level of difficulty in your:

 

 

difficulty

 

difficulty

difficulty

 

difficulty

 

 

difficulty

 

 

 

 

 

 

 

 

a.

Relationship with client

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Relationship with family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

Relationships with friends

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

Physical health

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e.

Finances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f.

Functional abilities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Time for yourself to do the things you enjoy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

134. How confident are you that you will have the ability to continue to provide care?

 

 

 

 

 

 

 

 

 

 

 

 

Very confident (Skip to 135)

Somewhat confident (Skip to 135)

 

Not very confident

 

 

 

 

 

a. What is the main reason you may be unable to continue to provide care?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

135. Assessor/CM: Is the caregiver in crisis?

No

 

Yes; check all that apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Financial

 

Emotional

 

Physical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

L. CAREGIVER SECTION, CONTINUED

136. Ask the caregiver to answer the following about the client. (An answer of

 

 

 

 

 

 

 

Don’t

 

“Yes, a change” indicates that there has been a change in the last year

 

Yes, a

 

No

 

know

 

caused by thinking and memory problems.)

 

change

 

change

 

or N/A

 

 

a. Problems with judgment (problems making decisions, bad financial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

decisions, problems with thinking)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Less interest in hobbies/activities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Repeats the same things over and over (questions, stories, or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

statements)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Trouble learning how to use a tool, appliance, or gadget (TV, radio,

 

 

 

 

 

microwave, remote control)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Forgets the correct month or year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Trouble handling complicated financial affairs (balancing checkbook,

 

 

 

 

 

income taxes, paying bills)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g. Trouble remembering appointments

h. Daily problems with thinking or memory

  

  

Adapted from the Eight-item Informant Interview to Differentiate Aging and Dementia,” a copyrighted instrument of Washington University, St. Louis, Missouri. Copyright 2005. All rights reserved.

Notes & Summary:

17DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

[This page is intentionally left blank]

18DOEA 701B, April 2013

Florida Department of Elder Affairs: 701B Comprehensive Assessment

WHY ARE WE COLLECTING YOUR SOCIAL SECURITY NUMBER?

We are required to explain that your Social Security number is being collected pursuant to Title 42 Code of Federal Regulations, Section 435.910, to be used for screening and referral to programs or services that may be appropriate for you.

The provision of your Social Security number is voluntary, and your information will remain confidential and protected under penalty of law. We will not use or give out your Social Security number for any other reason unless you have signed a separate consent form that releases us to do so.

19DOEA 701B, April 2013