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.
Question | Answer |
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Form Name | DOEA 701B Form |
Form Length | 19 pages |
Fillable? | Yes |
Fillable fields | 1316 |
Avg. time to fill out | 38 min 17 sec |
Other names | 701b, florida 701b training, 701b certification, 701b assessment |
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Florida Department of Elder Affairs |
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701B Comprehensive Assessment |
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Rule: |
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Provider ID: |
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Provider |
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Assessor/CM ID: |
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Assessor/Case |
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Manager (CM) Name: |
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Signature: |
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A. DEMOGRAPHIC SECTION |
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1.ASSESSOR/CM: What is the purpose of this assessment?
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Initial Annual Health Living situation |
Caregiver Environment |
Income |
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2. |
Social Security number: |
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3. |
Name: a. First: |
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b. Middle initial: |
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c. Last: |
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4. |
Medicaid number: |
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5. |
Phone number: |
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6. |
Date of birth (mm/dd/yyyy): |
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7. |
Sex: |
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Male |
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Female |
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8. |
Race (Mark all that apply): |
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White |
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Black/African American |
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Asian |
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American Indian/Alaska Native |
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Native Hawaiian/Pacific Islander |
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Other |
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Ethnicity: |
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Hispanic/Latino |
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Other |
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10. |
Primary language: |
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English |
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Spanish |
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Other: |
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11. |
Does client have limited ability reading, writing, speaking, or understanding English? No |
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Yes |
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12. |
Marital status: |
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Married |
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Partnered |
Single |
Separated |
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Divorced |
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Widowed |
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13.ASSESSOR/CM: Current Physical Location Address (If type is a facility, enter facility name.)
a. Street:
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b. City: |
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c. ZIP code: |
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d. Type: |
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Private residence |
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Assisted living facility (ALF) |
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Nursing facility |
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Hospital |
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Adult day care |
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Other |
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e. Name: |
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14. |
Home Address (If different from current physical location) |
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a. Street: |
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b. City: |
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c. ZIP code: |
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15. |
Is client’s home address public housing? No Yes |
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Mailing Address (If different from current physical location) |
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16. |
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a. Street: |
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b. City: |
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c. State: |
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d. ZIP code: |
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1DOEA 701B, April 2013
Florida Department of Elder Affairs: 701B Comprehensive Assessment
A. DEMOGRAPHIC SECTION, CONTINUED
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ASSESSOR/CM: Assessment date: (mm/dd/yyyy) |
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18. |
ASSESSOR/CM: Assessment site: |
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Home |
ALF Nursing facility Hospital |
Adult day care |
Other |
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19. |
ASSESSOR/CM: Referral date: (mm/dd/yyyy) |
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20. |
ASSESSOR/CM: Referral source: |
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Self/Family |
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Nursing facility |
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Case management agency |
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CARES |
Aging out |
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Hospital |
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Department of Children and Families |
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Other |
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APS: Select level of APS risk |
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High |
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Intermediate |
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Low |
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21. |
ASSESSOR/CM: Transitioning out of a nursing facility? |
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No |
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Yes |
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22. |
ASSESSOR/CM: Imminent risk of nursing home placement? |
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No |
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Yes |
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23. |
Do you need outside assistance to evacuate? |
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No |
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Yes |
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24. |
Are you enrolled on a special needs registry? |
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No |
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Yes |
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25. |
Is there a primary caregiver? |
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No |
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Yes |
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26. |
Living situation: |
With primary caregiver |
With other caregiver |
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With other |
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Alone |
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27. |
Individual monthly income: |
$ |
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Refused |
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Refused |
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N/A |
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28. |
Couple monthly income: |
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$ |
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29. |
Estimated total individual assets: |
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$ |
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$0 to $2,000 |
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$2,001 to $5,000 |
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$5,001 or more |
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Refused |
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30. |
Estimated total couple assets: |
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$ |
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$0 to $3,000 |
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$3,001 to $6,000 |
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$6,001 or more |
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Refused |
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N/A |
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31. |
Are you receiving S/NAP (food stamps)? |
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No |
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Yes |
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32. |
Do you need other assistance for food? |
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No |
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Yes |
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33. ASSESSOR/CM: Is someone besides the client providing answers to questions? |
No (Skip to 34) Yes |
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a. Name |
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b.Relationship: |
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34. Besides your own children, how many children under age 19 do you live with and provide care for? |
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(if zero, skip to 35) |
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a. How many are grandchildren? |
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Name(s): |
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b. How many are other related children? |
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c. How many are other |
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Name(s): |
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35. How many disabled adults age 19 to 59 do you live with and provide care for? (if zero, skip to 36) |
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a. How many are grandchildren? |
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Name(s): |
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b. How many are other relatives? |
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Name(s): |
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c. How many are other |
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Name(s): |
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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 |
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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:
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Sock Blue Bed |
Total number of correct words: None |
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One Two Three |
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“Thank you. I will ask you to repeat these to me again later.” |
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39. |
Please tell me what year it is: |
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Correct |
Missed by one year |
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Missed by two to five years |
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Missed by five or more years |
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No answer |
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40. |
Please tell me what month it is: |
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Correct |
Missed by one month |
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Missed by two to five months |
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Missed by five or more months |
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No answer |
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41. |
Please tell me what day (of the week) it is: |
Correct Incorrect |
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No answer |
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42. |
“Let’s go back to an earlier question. What were those words I asked you to repeat back to me?” |
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Sock Blue Bed |
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43.ASSESSOR/CM: Number of words correctly recalled without prompting: None One Two Three
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44. |
Have any friends or family members expressed concern about your memory? |
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No |
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Yes |
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45. |
Have you become concerned about your memory or had problems |
No (Skip to 47) |
Yes |
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remembering important things? |
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46. |
How often do you have problems remembering things? |
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Always Often Sometimes Rarely Don’t know |
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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
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Excellent |
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Very Good |
Good |
Fair |
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Poor |
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48. |
How would you rate your overall health at this time? |
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49. |
Compared to a year ago, how would you rate your health? |
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Much better |
Better |
About the same |
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Worse |
Much worse |
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50. |
How often do you change or limit your activities out of fear of falling? |
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Never |
Occasionally |
Often |
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All of the time |
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51. |
How many times have you fallen in the last six months? # |
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52. |
How often are there things you want to do but cannot because of physical problems? |
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Never |
Occasionally |
Often |
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All of the time |
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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?
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Always |
Most of the time |
Rarely |
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Only in an emergency |
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Never |
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55. |
Do you drive a car or other motor vehicle? |
No |
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Yes |
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56. |
How often do finances/insurance allow you to obtain health care and medications when you need them? |
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Always |
Most of the time |
Rarely |
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Only in an emergency |
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Never |
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57. |
Have you visited the emergency room (ER) or been admitted to the hospital within the last year? |
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No Yes: |
How many times? ER# |
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Hospital # |
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58. |
In the last year were you in a nursing or rehabilitation facility? |
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No |
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Yes |
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59. |
Are you usually able to climb two or three stair steps? |
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No |
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Yes Don’t know |
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60. |
ASSESSOR/CM: Are there any stairs within the dwelling or leading into/out of the dwelling? No Yes |
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61. Are you usually able to carry a full glass of water across a room without spilling it? |
No |
Yes Don’t know |
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62. Has a doctor told you that you currently have vision problems? |
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No |
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Yes |
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Blind (If blind, skip to 63) |
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a. Have you had an eye exam in the past year? |
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No |
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Yes |
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b. Do you bump into objects (people, doorways) because you don’t see them? |
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No |
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Yes |
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c. Is your vision getting worse than it was last year? |
No In one eye |
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Slightly worse Much worse |
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63. Has a doctor told you that you currently have hearing problems? |
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No |
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Yes |
Deaf (If deaf, skip to 64) |
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a. Have you had a hearing exam in the past year? |
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No |
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Yes |
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b. Can you understand words clearly over the telephone? |
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No |
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Yes |
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c. Is your hearing worse than it was last year? |
No In one ear |
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Slightly worse Much worse |
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64. |
ASSESSOR/CM: Does client rely on writing, gestures, or signs to communicate? |
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No |
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Yes |
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65. |
ASSESSOR/CM: Are the client’s words formed properly, not slurred or clipped? |
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No |
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Yes |
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66. |
ASSESSOR/CM: Are any sensory aids or assistive devices currently used? |
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No |
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Yes |
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If yes, please list the type(s) used: |
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67. |
ASSESSOR/CM: Is there an unmet need for a sensory aid or assistive device? |
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No |
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Yes |
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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?
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No |
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Uses |
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Needs |
Needs |
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Needs total |
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Task |
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assistance |
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assistive |
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supervision |
assistance (but |
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assistance |
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needed |
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device |
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or prompt |
not total help) |
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(cannot do at all) |
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a. Bathing |
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b. Dressing |
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c. Eating |
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d. Using the bathroom |
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e. Transferring |
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f. Walking/Mobility |
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69. ASSESSOR/CM: Is there an unmet need for an ADL assistive device? |
No |
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Yes |
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If yes, type(s) needed:
70. How much assistance do you have with the following tasks?
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Has |
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Task |
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No |
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assistance |
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assistance |
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Always has |
most of the |
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Rarely has |
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Never has |
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needed |
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assistance |
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time |
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assistance |
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assistance |
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a. Bathing |
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b. Dressing |
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c. Eating |
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d. Using the bathroom |
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e. Transferring |
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f. Walking/Mobility |
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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?
|
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No |
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Uses |
|
Needs |
|
Needs |
|
Needs total |
|
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Task |
|
assistance |
|
assistive |
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supervision |
|
assistance (but |
|
assistance |
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|||
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needed |
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device |
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or prompt |
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not total help) |
(cannot do at all) |
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a. Heavy chores |
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b. Light housekeeping |
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c. Using the telephone |
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d. Managing money |
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e. Preparing meals |
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f. Shopping |
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g. Managing |
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medication |
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h. Using transportation |
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72. ASSESSOR/CM: Is there an unmet need for an IADL assistive device? |
|
No |
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Yes |
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If yes, type(s) needed:
73. How much assistance do you have with the following tasks?
|
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Has |
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Task |
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No |
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assistance |
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||
|
assistance Always has |
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most of the |
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Rarely has |
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Never has |
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needed |
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assistance |
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time |
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assistance |
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assistance |
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a. Heavy chores |
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b. Light housekeeping |
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c. Using the telephone |
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d. Managing money |
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e. Preparing meals |
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f. Shopping |
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g. Managing medication |
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h. Using transportation |
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|
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.
|
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Past |
Current |
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Health Conditions |
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Acid reflux/GERD |
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Allergies, list:
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Amputation, site: |
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Anemia |
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Severe Moderate |
Mild |
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Arthritis, type: |
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Bed sore(s) (Decubitus), location:
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Blood pressure |
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High |
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Low |
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Broken bones/fractures, location:
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Cancer, site: |
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Chlamydia |
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Cholesterol |
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High |
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Low |
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Dehydration |
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Diabetes |
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IDDM |
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NIDDM |
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Dizziness |
|
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Constant |
|
Frequent |
Occasional |
Rare |
|||
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Fibromyalgia |
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Gallbladder |
|
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Removal |
|
Problems |
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Gonorrhea |
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Heart problems |
|
|
Pacemaker |
|
CHF |
MI |
Other |
|||
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|
Head, brain, or spinal cord trauma |
|
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Herpes |
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Human Immunodeficiency Virus (HIV) |
|
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Human Papilloma Virus (HPV)/Genital warts
|
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Constant |
|
Frequent |
|
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Occasional |
|
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Rare |
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|
Incontinence, bladder |
|
|
||||||||||||
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Incontinence, bowel |
Constant |
Frequent |
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Occasional |
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Rare |
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Kidney problems or renal disease |
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End stage? |
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No |
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Yes |
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Liver problems |
Cirrhosis |
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Hepatitis |
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Lung problems |
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Emphysema |
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Asthma |
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Pneumonia |
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COPD |
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Lupus |
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Multiple Sclerosis |
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Muscular Dystrophy
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Osteoporosis |
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Parkinson’s disease |
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Paralysis |
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Full |
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Partial |
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Local, site: |
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Seizure disorder, type & frequency:
7DOEA 701B, April 2013
Florida Department of Elder Affairs: 701B Comprehensive Assessment
F. HEALTH CONDITIONS & THERAPIES SECTION, CONTINUED
|
Past |
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Current |
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Health Conditions |
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Shingles |
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Stroke/CVA |
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Syphilis |
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Thyroid problems/Graves/Myxedema Hyper Hypo |
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Tumor(s), site: |
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Ulcer(s), site:
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Urinary Tract Infection (UTI) |
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Other: |
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75. Provide information on the frequency of current therapies or specialty care:
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Several |
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Several |
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N/A or |
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times |
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times |
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Treatment type: |
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None |
Monthly |
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Weekly |
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a week |
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Daily |
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a day |
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a. Bladder/bowel treatment |
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b. Catheter, type: |
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c. Dialysis |
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d. Insulin assistance |
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e. IV Fluids/IV Medications |
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f. |
Occupational therapy |
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g. Ostomy, site: |
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h. Oxygen |
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i. |
Physical therapy |
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j. |
Radiation/Chemotherapy |
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k. Respiratory therapy |
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l. |
Skilled nursing |
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m. Speech therapy |
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n. Suctioning |
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o. Tube feeding |
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p. Wound care/Lesion irrigation |
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q. Other therapy, type: |
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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? |
|
|||||
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Neither satisfied nor dissatisfied |
|
Dissatisfied |
|
Very dissatisfied |
|
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|
|
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 |
|||||||
all |
days |
days |
day |
||||
|
|
|
|||||
a. Little interest or pleasure in doing things |
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b. Feeling down, depressed, or hopeless |
||||||||
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c. Trouble falling or staying asleep, or sleeping too much |
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d. Feeling tired or having little energy |
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e. Poor appetite or overeating |
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f. Feeling bad about yourself – or that you are a failure or |
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have let yourself or your family down |
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g. Trouble concentrating on things, such as reading the |
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||||
|
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newspaper or watching television |
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h. Moving or speaking so slowly that other people noticed – |
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Or, the opposite, being so fidgety or restless that you |
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|
|
have been moving around a lot more than usual |
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i. Thoughts that you would be better off dead or of hurting |
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||||
|
|
yourself in some way* |
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|
*Thoughts of suicide or
ASSESSOR/CM: If the client answered “Not at all” to
79. How difficult have these problems made it for you in your daily life activities and interactions with others?
|
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Not difficult at all |
Somewhat difficult |
Very difficult |
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Extremely difficult |
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|
80. Are you currently working with a professional to help with this condition? |
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No |
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Yes (Skip to 81) |
||||
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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 |
|||
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|||||||
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|
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,
|
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Several |
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Problem behaviors |
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Not at all |
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Once |
|
days |
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a. Forgetful or easily confused |
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b. Gets lost or wanders off |
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c. Easily agitated or disruptive |
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d. Sexually inappropriate |
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e. Threatens or is verbally hostile* |
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|
f. Physically aggressive or violent* |
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g. Intentionally injures or harms him/herself* |
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h. Expresses suicidal feelings or plans* |
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i. Hallucinates, hears/sees things that are not |
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there* |
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j. Other: |
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||||||
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More |
Nearly |
than half |
every |
the days |
day |
*Thoughts of suicide or
|
|
83. ASSESSOR/CM: Does client need supervision? |
No |
Yes |
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|||
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Notes & Summary: |
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|
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: |
|
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||
|
a. Exterior issues(s): |
Road |
|
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Driveway |
|
Yard |
|
Ramp |
|
Windows |
Roof |
||
|
|
b. Interior issues(s): |
Doors |
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Stairs |
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Floor |
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Walls |
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Ceiling |
Lights |
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c. Restroom issues(s): |
|
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Door |
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Handrails |
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Tub |
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Shower |
Toilet |
||
|
|
d. Utility issue(s): |
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Plumbing |
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Water |
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Electric |
Gas |
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e. Furniture issue(s): |
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Chair |
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Couch |
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Bed |
Table |
||
|
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f. Telephone issue(s): |
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Broken |
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No phone |
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Disconnected/No service |
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g. Temperature issue(s): |
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Heat |
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Smoke detector |
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Air conditioning |
|||||
|
|
h. Unsanitary condition(s): |
|
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Odors |
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Insects |
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Rodents |
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Accumulating items or garbage |
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Floors or pathways |
|
|||||
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|
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
|
|
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|
No |
|
Yes |
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||||
87. |
Do you usually eat at least two meals a day? |
|||||||||
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|
88. |
On a typical day, what types of food do you eat for: |
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a. |
Breakfast: |
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b. |
Lunch: |
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c. |
Dinner: |
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d. |
Snacks: |
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||
89. |
Do you eat alone most of the time? |
No |
Yes |
|
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|
|||
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 |
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|||||
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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
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# |
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|||||||||
|
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92. |
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On average, how many servings of dairy products do you have every day? (One “serving” of |
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dairy is about a slice of cheese, a cup of yogurt, or a cup of milk or dairy substitute.) |
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93. |
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Estimate your current height and weight: |
Height: |
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inches |
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Weight: |
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lbs. |
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94. |
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Have you lost or gained weight in the last few months? Unsure (Skip to 95) |
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No (Skip to 95) Yes |
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a.How much? |
Less than five pounds |
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Five to ten pounds |
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Ten pounds or more |
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b.Was the weight loss/gain on purpose (i.e., dieting or trying to lose/gain weight)? No |
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Yes |
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95. |
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Are you on a special diet(s) for medical reasons? |
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No (Skip to 96) |
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Yes; check any/all: |
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Calorie supplement |
Low fat/cholesterol |
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Low salt/sodium |
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Low sugar/carb |
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Other |
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a. How long have you been on this diet? |
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b. Why are you on this diet? |
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96. |
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Do you have any problems that make it hard for you to chew or swallow? No |
Yes; check any/all: |
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Mouth/tooth/dentures |
Pain or difficulty swallowing |
Taste |
Nausea |
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Saliva production |
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Other, describe: |
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97. |
What working appliances do you have for storing/preparing food? None |
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Refrigerator Microwave |
Toaster/Oven |
Stove |
Other: |
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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 |
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
ASSESSOR/CM: Check the original bottles in the medicine cabinet, nightstand, and refrigerator, as well as
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Taken as |
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Prescribed |
Prescribed |
prescribed? |
Administration |
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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
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Approx. |
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date of |
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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
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104. |
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ASSESSOR/CM: Are the client’s medications managed by a facility/caregiver? |
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No |
Yes |
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N/A |
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105. |
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ASSESSOR/CM: In your opinion, are the client’s medications managed properly? |
No Yes |
N/A |
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106. |
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ASSESSOR/CM: Should client have a new medication review by a doctor or |
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No |
Yes |
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N/A |
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pharmacist? |
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107. |
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How many days in a typical week do you drink alcohol? |
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Refused (Skip to 108) |
None (Skip to 108) |
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One to two |
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Three to five Six to seven |
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a. On the days when you have some alcohol, about how many drinks do you usually have? |
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One to two (Skip to 108) |
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Three to five |
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Six or more |
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b. About how many times in the last month have you had four or more drinks in a day? |
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None |
One to two |
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Three to five |
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Six or more |
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1 |
08. |
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Have you used any form of tobacco in the last six months? |
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No (Skip to 109) |
Yes: |
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a. What type(s)? |
Chewing tobacco |
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Cigarettes |
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Cigars |
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Snuff |
Other |
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b. About how many times do you use tobacco each day? |
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One to three |
Four to ten |
Eleven or more |
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109. |
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Do you regularly use drugs other than those required for medical reasons (i.e., controlled substances or |
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“street drugs”)? |
Refused (Skip to 110) No (Skip to 110) |
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Yes, what type(s): |
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a. About how often do you use these? |
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Rarely |
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Less than twice a month |
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Less than once a week |
Several times a week |
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Daily |
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Several times a day |
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b. How long have you been using that often? |
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Less than a year |
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One or more years |
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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 |
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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:
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Two to |
Once |
Several |
Every |
A few |
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About how often do you: |
Once a |
six times |
a |
times a |
few |
times |
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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.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
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1 |
19. |
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Caregiver sex: |
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Male |
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Female |
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120. |
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Caregiver race (Mark all that apply): |
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White |
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Black/African American |
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Asian |
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American Indian/ Alaska Native |
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Native Hawaiian/ Pacific Islander |
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Other |
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1 |
21. |
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Caregiver ethnicity: |
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Hispanic or Latino |
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Other |
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122. |
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Caregiver primary language: |
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English |
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Spanish |
Other |
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1 |
23. |
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Caregiver relationship to client: |
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Wife |
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Husband |
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Partner |
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Parent |
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Other relative |
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Other |
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124. |
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Caregiver address: |
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a. Street: |
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b. City: |
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c. State: |
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d. ZIP code: |
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125. |
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Caregiver phone number: |
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126. |
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Do you work outside the home? |
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No |
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Yes: |
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127. |
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Do you currently have anyone to assist you with providing care? |
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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
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client? |
No (Skip to 129) |
Yes, please provide the name and relationship to client: |
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a. First name |
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b. Last name: |
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c. Phone: |
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d. Relationship to client: |
Wife Husband |
Partner |
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Parent |
Other relative |
Other |
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129. How long have you been providing care for this client? |
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Less than six months |
Six to twelve months |
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One to two years |
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Two or more years |
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130. How many hours per week do you currently spend providing care for the client? |
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131. Do you need training or assistance in performing caregiving tasks? |
No |
Yes, please describe |
: |
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132. How much of a mental or emotional strain is it on you to provide care for the client? |
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None |
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Some strain |
A lot of strain |
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133. Considering other aspects of your life, |
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No |
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Little |
Some |
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Moderate |
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A lot of |
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please rate the level of difficulty in your: |
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difficulty |
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difficulty |
difficulty |
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difficulty |
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difficulty |
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a. |
Relationship with client |
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b. |
Relationship with family |
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c. |
Relationships with friends |
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d. |
Physical health |
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e. |
Finances |
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f. |
Functional abilities |
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g. Employment |
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h. Time for yourself to do the things you enjoy |
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134. How confident are you that you will have the ability to continue to provide care? |
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Very confident (Skip to 135) |
Somewhat confident (Skip to 135) |
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a. What is the main reason you may be unable to continue to provide care? |
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135. Assessor/CM: Is the caregiver in crisis? |
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Yes; check all that apply: |
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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 |
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Don’t |
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“Yes, a change” indicates that there has been a change in the last year |
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caused by thinking and memory problems.) |
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a. Problems with judgment (problems making decisions, bad financial |
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decisions, problems with thinking) |
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b. Less interest in hobbies/activities |
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c. Repeats the same things over and over (questions, stories, or |
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statements) |
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d. Trouble learning how to use a tool, appliance, or gadget (TV, radio, |
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microwave, remote control) |
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e. Forgets the correct month or year |
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f. Trouble handling complicated financial affairs (balancing checkbook, |
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income taxes, paying bills) |
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g. Trouble remembering appointments
h. Daily problems with thinking or memory
Adapted from the
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