DOEA 701B Form – Fill Out and Use This PDF

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

 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

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:

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):

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

 No

 Yes

 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

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

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

 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 Don’t 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

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

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









