Doh 4397 Form – Fill Out and Use This PDF

Resident’s Name: _________________________________________________________________________________

Facility Name: ________________________________________

Date of Evaluation: __________________________

SECTION 1: COMMUNICATION/DENTAL/VISION/HEARING

Can the individual Speak English?  Yes  No

Read English?  Yes  No

Write in English?  Yes  No

Can the individual understand instructions in English?

 Yes

 No

If no to any of the above, indicate dominant language: Speak:______________ Read:______________

Write:______________

Verbal Expression/Speech (check all that apply):

Easily Understood

 Yes

 No

Difficulty finding words or expressing self

 Yes

 No

Slurred or mumbled speech

 Yes

 No

Understands directions

Yes

No

SPEECH: Does the resident have a speech defect / impairment? Yes

 No

If yes, describe:___________________________________________________________________________________________

DENTAL Prosthetics: _____________________________________________________________________________________

VISION: Glasses:

Yes  No Glaucoma: L  R 

Legally Blind: L  R  Contact Lenses: Yes  No

Comments:______________________________________________________________________________________________

HEARING: Does the patient have a hearing deficit?

Yes

 No

Hearing Aid: L  R 

Comment(s): _____________________________________________________________________________________________

SECTION 2: CUSTOMARY ROUTINE

Sleeping routine:

Preferred wake up time: __________

Napping routine:

___________________

Preferred bedtime: ______________

Nighttime sleep pattern: ___________________

Comments: ______________________________________________________________________________________________

_________________________________________________________________________________________________________

Bathing routine:

Prefers

 Bath

 Shower

Frequency: ____________________________________________

Comments: ______________________________________________________________________________________________

_________________________________________________________________________________________________________

Eating routine: Food preferences (religious, cultural, other): _________________

_________________ ________________

Food dislikes: ___________________

___________________

___________________

Comments: ______________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Daily Events:

 Goes out __________days a week

 Stays busy with hobbies, reading, fixed daily routine

(check all that apply)

(Specify 1 – 7)

 Spends most time alone

 Contact with relatives/close friends ________days per week

(Specify 1 – 7)

 Spends most time watching TV

 Usually attends church, synagogue, mosque, etc.

 Prefers small group activities

 Prefers large group activities

Comments: ______________________________________________________________________________________________

_________________________________________________________________________________________________________

DOH-4397 Part B (03/08) Rev. 09/12

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SECTION 3: CONTINENCE STATUS/MANAGEMENT

Is the resident continent of urinary function?

 Yes

 No

Is the resident continent of bowel function?

 Yes

 No

IF ANSWER IS “NO” TO EITHER QUESTION, COMPLETE THIS SECTION, AS APPROPRIATE.

Urinary Incontinence

Bowel Incontinence

 Several times a week

 Day Only

 Several times a week

 Day only

 Daily

 Night only

 Daily

 Night only

 Day and night

 Day and night

Current management techniques

Current management techniques

 Prompting/reminding defers incontinence

 Uses incontinence pads/adult diapers:

 Timed voiding defers incontinence

 Day only

 Uses incontinence pads/adult diapers:

 Night only

 Day only

 Day and night

 Night only

Comments:

 Day and night

__________________________________________________________

Catheter (specify type) ____________________________

__________________________________________________________

Comments: _____________________________________

__________________________________________________________

_______________________________________________

Self-manage continence?  Yes  No

Self-manage continence?

 Yes  No

SECTION 4: PHYSICAL FUNCTION

TASK

LEVEL OF ASSISTANCE

COMMENTS

Eating:

 Independent: Able to feed self independently with or

Dentures

Upper

 Yes

 No

(Ability to feed self

without assistive device.

Lower

 Yes

 No

meals and snacks)

 Intermittent Assistance: Requires minimal,

Chewing difficulties

 Yes

 No

intermittent supervision and/or assistance.

 Continual Assistance: Requires constant assistance

Difficulty swallowing

Yes

 No

and/or supervision throughout meal.

Modified consistency

 Yes

 No

 Total Assistance: Unable to feed self, needs to be fed.

Specify ______________

Comments:

Unable to take nutrients orally, requires enteral nutrition.

Ambulation:

Independent: Walks and climbs and descends stairs

 Wheelchair

 Walker

(Ability to safely walk

independently with or without assistive device.

and move about once

 Quad cane

 Cane

in a standing position)

 Intermittent Assistance: Walks and climbs and

descends stairs with minimal, intermittent assistance

 Other: ____________________

and/or supervision.

 Continual Assistance: Walks and climbs and

Falls within the last 3 months?

 Yes  No

descends stairs with constant supervision and/or

Frequency #: _______________________

assistance.

 Total Assistance: Chairfast or bedfast. Requires total

Injury: ____________________________

Comments:

assistance for mobility.

DOH-4397 Part B (03/08) Rev. 09/12

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TASK

LEVEL OF ASSISTANCE

COMMENTS

Transferring:

 Independent: Able to transfer independently with or

Comments:

(Moving from bed to

without assistive device.

chair, on/off toilet,

in/out of shower or

 Intermittent Assistance: Transfers with minimal

tub)

human assistance and/or supervision.

 Continual Assistance: Unable to transfer but can bear

weight and pivot when transferred by at least one other

person.

 Total Assistance: Chairfast or bedfast, unable to

transfer, pivot, bear weight or turn self in bed.

TASK

LEVEL OF ASSISTANCE

COMMENTS

Toileting: (Getting to/from

 Independent: Able to toilet independently with or without

Ostomy

 Yes  No

and on/off the toilet,

assistive device.

Comments:

cleansing self after

 Intermittent Assistance: Able to toilet with minimal

elimination and adjusting

intermittent assistance and/or supervision.

clothing)

 Continual Assistance: Able to toilet with constant

assistance and/or supervision.

 Total Assistance: Unable to toilet. Requires total

assistance with toileting.

Bathing: (Getting in and

 Independent: Able to bathe or shower independently with

Comments:

out of tub or shower,

or without assistive device.

washing and drying entire

 Intermittent Assistance: Able to bathe or shower

body)

w/minimal intermittent assistance and/or supervision.

 Continual Assistance: Able to bathe or shower with

constant assistance and/or supervision.

 Total Assistance: Unable to use shower or tub. Bathed

in bed or at bedside.

Dressing: (Getting clothes

 Independent: Able to dress and undress independently

Comments:

from closets and drawers,

with or without assistive device.

dressing and undressing

 Intermittent Assistance: Able to dress and undress with

upper/lower body including

buttons, snaps, zippers,

minimal, intermittent assistance and/or supervision.

 Continual Assistance: Requires assistance throughout

socks and shoes)

the dressing and undressing process.

 Total Assistance: Requires another person to dress and

undress upper and lower body.

DOH-4397 Part B (03/08) Rev. 09/12

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SECTION 4: PHYSICAL FUNCTION Cont.

TASK

LEVEL OF ASSISTANCE

COMMENTS

Grooming: (Washing face,

 Independent: Able to groom self independently with or

Comments:

hair care, shaving,

without assistive device.

teeth/denture, fingernail

 Intermittent Assistance: Requires grooming utensils to

care, eyeglasses care)

be set up and placed within reach.

 Continual Assistance: Requires assistance throughout

the grooming process.

 Total Assistance: Depends entirely upon someone else

for grooming.

Transportation: (Physical

 Independent: Able to independently drive a regular or

Comments:

and mental ability to safely

adapted car; OR uses a regular or handicap accessible public

use a car, taxi, or public

bus, train or subway.

transportation [bus, train,

 Independent: But requests facility perform task.

subway)

 Intermittent Assistance: Able to ride in a car only when

driven by another person; AND/OR due to physical, cognitive

or mental limitations occasionally requires another person to

accompany him/her when using a bus, train or subway.

 Continual Assistance: Able to ride in a car only when

driven by another person; OR able to use a bus or handicap

van, train or subway only when assisted or accompanied by

another person.

 Total Assistance: Unable to ride in a car, taxi, bus or

van, and requires transportation by ambulance.

Laundry: (Ability to do own

 Independent: Able to independently take care of all

Comments:

laundry – to carry laundry

laundry tasks.

to and from washing

 Independent: But requests facility perform task.

machine, to use washer

 Intermittent Assistance: Able to do only light laundry,

and dryer, to wash small

items by hand)

such as minor hand wash or light washer loads. Needs

assistance with heavy laundry, such as carrying large loads

of laundry.

 Continual Assistance: Due to physical, cognitive or

mental limitations, needs continual supervision and

assistance to do any laundry.

Total Assistance: Unable to do any laundry.

Housekeeping: (Ability to

 Independent: Able to independently perform all

Comments:

safely and effectively

housekeeping tasks.

perform light housekeeping

 Independent: But requests facility perform task.

and heavier cleaning tasks)

 Intermittent Assistance: Able to perform only light

housekeeping (e.g., dusting, wiping kitchen counters) tasks

independently; AND/OR able to perform housekeeping tasks

with intermittent assistance or supervision from another

person.

 Continual Assistance: Unable to consistently perform

any housekeeping tasks unless assisted by another person

throughout the process.

Total Assistance: Unable to effectively participate in any

housekeeping tasks.

DOH-4397 Part B (03/08) Rev. 09/12

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TASK

LEVEL OF ASSISTANCE

COMMENTS

Shopping: (Ability to

 Independent: Able to plan for shopping needs and independently

Comments:

plan form, select and

perform shopping tasks, including carrying package.

purchase items in a

 Independent: But requests facility perform task.

store and to carry them

home or arrange

 Intermittent Assistance: Able to do only light shopping and carry

delivery)

small packages, but needs someone to do occasional major shopping.

 Continual Assistance: Unable to go shopping alone, but can go

with someone to assist; OR unable to go shopping but is able to

identify items needed, place orders, and arrange for home delivery.

 Total Assistance: Needs someone to do all shopping and

errands.

Ability to use a

 Independent: Able to dial numbers and answers calls

Comments:

Telephone: (Ability to

appropriately and as desired.

answer the telephone,

 Independent: But requests facility perform task.

dial numbers, and

 Intermittent Assistance: Able to use a specially adapted

effectively use the

telephone (i.e., large numbers on the dial pad, teletype phone for the

telephone to

deaf) and call essential numbers; able to answer the telephone and

communicate)

carry on a normal conversation but has difficulty with placing calls;

able to answer the telephone only some of the time or is able to carry

on only a limited conversation.

 Continual Assistance: Unable to make calls or answer the

telephone at all, but can listen if assisted with equipment.

 Total Assistance: Totally unable to use the telephone. Requires

someone else to make calls.

Behaviors of Note: (check all that apply):

 Wanders Day/Night  Sleep disturbance  Confused  Depressive Feelings  Anxious

 Withdrawn/Refuses to Socialize

 Agitated (repeated vocalizations, screaming, shouting, moaning, cursing, fidgeting, etc.)

 Other:____________________

DOH-4397 Part B (03/08) Rev. 09/12

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Signature(s) of ALR staff participating in this evaluation.

Name: _________________________________________

Title: ____________________

Date: ___________

Name: _________________________________________

Title: ____________________

Date: ___________

Name: _________________________________________

Title: ____________________

Date: ___________

Name(s) of others participating in this evaluation.

Name: ___________________________________________

Relationship: ______________

Date: ___________

Name: ___________________________________________

Relationship: ______________

Date: ___________

DOH-4397 Part B (03/08) Rev. 09/12

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