Resident Assessment Form – Fill Out and Use This PDF

Date of Assessment: ______________

Date of Admission __________________

RESIDENT INFORMATION

Name (First, MI, Last)

Date of Birth (mm/dd/yyyy)

Sex

Marital Status

Rm/Apt. #

Male

Female

Single

Married

Divorced/Separated

Widow(er)

Is Able to Safely Operate Key-Locking Devices

Yes

No

Is a Veteran

Yes

No

Is Able to Safely Use Poisonous Personal Care and Toiletry Items

Yes

No

Is Able to Safely Use Other Poisons (such as cleaning supplies)

Yes

No

HEALTH PROBLEMS (Check All That Currently Apply)

Anemia

Hearing impairment (H.O.H., deafness)

Arthritis and other joint limitations or injuries

Heart trouble (angina, CHF, MI)

Bowel/bladder problems

Hypertension

Brain Injury (stroke, CVA, TIA, memory loss)

Mental Illness

Cancer, Leukemia or tumor

Respiratory problems (asthma, emphysema, COPD)

Dementia (OBS, Alzheimer’s, Huntington’s, Pick’s)

Skin Problems (decubitus ulcer, lesions, rashes)

Surgery with residual effects (drainage, amputation,

Developmental Disorder

paralysis, pain, fatigue)

Diabetes

Tremors (Parkinson’s)

Digestive disorders (ulcers, diverticulosis)

Visual impairments (cataracts, glaucoma, blindness)

Edema

Other (please list):

Effects of stroke (CVA, TIA, memory loss)

Effects of osteoporosis or fractures

Hardening of arteries (ASHD, poor circulation)

EXCLUDABLE CONDITIONS (Check All That Currently Apply)

Exception request submitted and

Exception request submitted;

approved by the Department?

pending Department approval

Ventilator dependency

Yes

No

Stage III and IV decubiti or vascular ulcers – not in a

Yes

No

healing stage

Continuous intravenous fluids

Yes

No

Reportable infectious disease, such as TB, requiring

Yes

No

isolation and/or special precautions

Nasogastric tubes

Yes

No

Physical restraints

Yes

No

Continuous skilled nursing care 24 hours a day

Yes

No

Commonwealth of Pennsylvania

Resident Assessment Form

Office of Long-Term Living

Page 1

3/11

The following Excludable Conditions do not require an

If no, was

Exception

exception

request

exceptions request if the individual is capable of self-

Capable of self-administration/

request

submitted;

administration/ self-care or administered by a licensed health

care or administered by

submitted and

pending

professional/other qualified individual:

licensed health profession/other

approved by

Department

qualified individual

the

approval

(check all that apply)

Department?

Gastric tubes

Yes

No

Yes

No

Tracheostomy

Yes

No

Yes

No

Sliding scale insulin administration

Yes

No

Yes

No

Intermittent intravenous therapy

Yes

No

Yes

No

Insertions, sterile irrigation and replacement of a

Yes

No

Yes

No

catheter

Oxygen

Yes

No

Yes

No

Inhalation therapy

Yes

No

Yes

No

Skilled nursing care 24 hours a day provided on a

Yes

No

Yes

No

temporary or intermittent basis

MEDICATIONS (List All Current Medications at Time of Assessment)

Prescription Medications

Dosage

Frequency

Physician/Pharmacy

Reason for Medication/Comments

Commonwealth of Pennsylvania

Resident Assessment Form

Office of Long-Term Living

Page 2

3/11

Independent

Requires

Requires

with or

Requires full

prompting or

physical

without

physical

N/A

cueing to

assistance to

assistive

assistance

complete

complete

devices

Independent

Requires

Requires

with or

Requires full

prompting or

physical

without

physical

N/A

cueing to

assistance to

assistive

assistance

complete

complete

devices

PERSONAL CARE – Grooming/Bathing

Bathing

Dental/Mouth Care

Hair Care

Shaving

Toe/Fingernail Care

PERSONAL CARE - Toileting

Bladder Control

Bowel Control

Special Equipment Required

List:

Catheter/Ostomy

PERSONAL CARE – Dressing/Undressing

Commonwealth of Pennsylvania

Resident Assessment Form

Office of Long-Term Living

Page 3

3/11