Form Living Assessment – Fill Out and Use This PDF

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Resident Name __________________________________	Date Completed ______________________
Date of Birth ____________________________________

Assisted Living Manager’s Assessment

This form is to be completed by the Assisted Living Manager or their designee. Questions noted with an asterisk are “triggers” for awake overnight staff.

Instructions: Record score in the blank next to each question.

				Activities of Daily Living
13.*			Resident Eats
	0			Independently
	1			With supervision, or set-up, or cuing and coaching
	2			With physical assistance or use of adaptive devices, such as built up utensil, plate guard, or
				Geri-cup, to feed self
			*3 Must be fed or needs tube feeding
14.*			Resident’s Mobility (moves from place to place)
	0			Independently
	1			With supervision, or stand-by, or cuing and coaching
			*2 One-person physical assistance
			*3 Two-person physical assistance, or needs complete mechanical assistance (e.g., Hoyer Lift)
15.*			Resident Transfer to Bed, Chair, or Toilet
	0			Independently (or with assistive device)
	1			With supervision, or stand-by or set-up, or cuing and coaching
			*2 One-person physical assistance
			*3 Two-person physical assistance, needs complete assistance
16.*			Bed Mobility (how resident moves to and from lying position, turns side to side, and positions body
			while in bed)
	0			Independently (or with assistive device)
	1			With supervision, or stand-by or set-up, or cuing and coaching
	*2			One-person physical assistance
	*3			Two-person physical assistance, needs complete assistance
17.*			Resident Use of Stairs
	0			Independently (or with assistive device)
	1			With supervision, or stand-by, or cuing and coaching
	2			One-person physical assistance
	3			Two-person physical assistance, or unable to use stairs
18.*			Resident Continence
	0			Independently
			*1 With supervision, or stand-by or set-up, or cuing and coaching

*2 Needs physical assistance from one other person

*3 Incontinent, needs complete assistance

19.Resident Completes Bathing 0 Independently

1 With supervision, or stand-by or set-up, or cuing and coaching

2 Needs physical assistance (e.g., help in and out of tub, washing hair)

3 Must be bathed, needs complete assistance or mechanical assistance (e.g., Hoyer Lift)

20.Resident Completes Grooming (teeth, make-up, shaving, hair) 0 Independently

1 With supervision, or stand-by or set-up, or cuing and coaching 2 Needs physical assistance

3 Must be groomed, needs complete assistance

Form 4506 Revised 9-15-09

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Resident Name __________________________________	Date Completed ______________________
Date of Birth ____________________________________

21.Resident Gets Dressed/Changes Clothes 0 Independently

1 With supervision, or stand-by or set-up, or cuing and coaching 2 With physical assistance

3 Must be dressed, needs complete assistance

21(a)

Add scores for Items 13 - 21. Enter total in blank space at left.

Instrumental Activities of Daily Living

Note: Incapacities identified in this section do not imply services will be provided.

Instructions: Check the letter that most closely reflects the resident’s capabilities.

22.Resident Can Prepare Light Meal

A – Independent, plans and prepares adequate meals

B – With supervision, set-up, or cuing and coaching

C – One-person physical assistance

D – Unable to prepare meals

23.Resident Can Do Light Chores

A – Independent

B – With supervision, set-up, or cuing and coaching

C – One-person physical assistance

D – Unable to do light chores

24.Resident Can Do Shopping

A – Independent

B – With supervision or cuing and coaching (e.g., choosing items)

C – With one-person physical assistance/someone to go with them

D – Unable to do shopping

25.Ability to Manage Finances

A – Family or resident manages all financial matters independently, writes checks, pays bills/rent, goes to bank

B – With supervision, writes checks, pays bills/rent, goes to bank

C – Manages day-to-day purchases, but needs help with purchases and banking D – Unable to manage finances or handle money

26.Transportation

A – Travels by self, all modes of transportation

B – Needs some assistance/escort

C – Complete assistance/needs specialized vehicle

27.Resident Can Use Telephone

A – Independent

B – With assistance dialing/using directory

C – Unable to use telephone

Form 4506 Revised 9-15-09

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Resident Name __________________________________	Date Completed ______________________
Date of Birth ____________________________________

Behaviors/Communication

Does the resident exhibit any of the following behaviors? Check the appropriate box to indicate frequency of each behavior. For scoring purposes use the highest frequency noted. See the User’s Guide for definitions of frequency.

Explain ________________________________________________________________________________________________

Explain ________________________________________________________________________________________________

Explain ________________________________________________________________________________________________

Explain ________________________________________________________________________________________________

32.* Disruptive behaviors: Frequency of behavior(s) (check appropriate response):

Explain ________________________________________________________________________________________________

Explain ________________________________________________________________________________________________

Form 4506 Revised 9-15-09

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Resident Name __________________________________	Date Completed ______________________
Date of Birth ____________________________________

34.* Resistive/uncooperative behaviors: Frequency of behavior(s) (check appropriate response):

Explain ________________________________________________________________________________________________

35.* Communication (check and/or explain appropriate response):

Explain ________________________________________________________________________________________________

36.Eating patterns and food preferences (check all that apply):

Eats full meals		Eats only two meals	Eats small portions	Finger foods
Eats only what they want, but maintains weight
Eats only when they want		Supplements (type ordered) ____________________________________________
Prefers:	Fruit	Vegetables	Meats	Snacks or snack foods

Explain ________________________________________________________________________________________________

Daily Social and Recreational Needs

Explain ________________________________________________________________________________________________

38.Spiritual needs and status ______________________________________________________________

_____________________________________________________________________________________

39.Education/Work History (check/complete all that apply):

Did not complete high school

Completed high school or GED

College

Lifetime or last occupation _______________________________________________________________

40.Interests/Hobbies: ____________________________________________________________________

Form 4506 Revised 9-15-09

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Resident Name __________________________________	Date Completed ______________________
Date of Birth ____________________________________

41.Activity Status (interest and ability to participate in, check and explain):

A. Structured and group activities

Yes

No

Varies

Explain _______________________________________________________________________________________________

B. Self-directed activities

Yes

No

Varies

Explain _______________________________________________________________________________________________

42.Current Daily Routine (e.g., up in the morning, bedtime, normal sleep cycle prior to move in, meal time preferences)

43.Interest/participation in programs away from facility (e.g., Senior Centers, Adult Day Care, or Rehabilitation Programs)

Print Name of Person Completing Assessment: _____________________________________________________

Position of Person Completing Assessment: _______________________________________________________

Date Completed: ________________________________

______________________________________________

Signature of Person Completing Assessment

Form 4506 Revised 9-15-09