Va Uai Form PDF Details

The Virginia Uniform Assessment Instrument, often abbreviated as the VA UAI form, serves as a comprehensive tool designed to assess the needs and background information of individuals requiring long-term care services within Virginia. This detailed document gathers a wide array of vital information, commencing with basic identification and background details such as the client's name, Social Security Number (SSN), address, and other personal identifiers. It delves deeper by inquiring about the client's living arrangements, including whether they live alone or with others, and details regarding their domicile. The form also addresses the physical health of the client, querying about current medical problems, medications, and any hospital admissions within the past 12 months, highlighting the form's thorough nature in assessing an individual's health status. Furthermore, this instrument touches on financial aspects by asking about income sources, types of health insurance, and the client's eligibility for various assistance programs, making it a holistic tool for evaluating the needs of clients in a bid to provide appropriate care and support services. The VA UAI form essentially acts as a critical connector between clients and the services they require, whether those needs are in home care, medical care, or financial assistance, showcasing its role in facilitating long-term care planning and coordination.

QuestionAnswer
Form NameVa Uai Form
Form Length12 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min
Other namesvirginia uniform assessment instrument, certification uai, what is a uai online, virginia uai form

Form Preview Example

VIRGINIA UNIFORM ASSESSMENT INSTRUMENT

IDENTIFICATION/BACKGROUND

Dates: Screen

/

AssessmentReassessment __ /

Client

Name:

 

 

Client

SSN:

 

 

(Last)

(First)

(Mlddle ImtlaI)

 

 

Address:

 

 

 

 

 

 

 

 

(Street)

 

(City)

(State)

(Zip Code)

Phone:

(

)

 

City/County

Code:

 

Directions

 

to House:

 

 

Pets?

Birthdate:

 

/

/

 

Age:

 

 

 

Sex:

__

Male

0 __ Female

1

(Month)

(Day)

 

(Year)

 

 

 

 

 

 

 

 

 

Marital Status:

__

Married

0

__ Widowed 1

__

Separated

2

Divorced

3

__

Single 4

Unknown 9

Race:

 

 

 

Education:

 

 

 

Communication of Needs:

 

White 0

 

 

 

Less than High School 0

Verbally,Enghsh 0

 

Black/African

American 1

 

Some

High

School 1

 

Verbally,

Other

Language 1

 

American Indian

2

 

High

School

Graduate

2

Specify

 

 

 

Oriental/Asian

3

 

 

Some

College

3

 

Sign Language/Gestures/Device

2

Alaskan Native 4

 

 

College Graduate 4

 

Does Not Commumcate 3

 

Unknown9

 

 

 

Unknown9

 

 

HearingimpalredP

 

 

EthnicOrigin

 

 

 

Specify

 

 

 

 

 

 

 

 

 

Name:

Relationship:

 

Address:

Phone:(H)

(W)

Name:

Relationship:

 

Address:

Phone:(H)

tW)

Name of Primary Physician:

Phone:

 

Address:

 

 

Who called:

(Name)(RelahontoChent)(Phone)

Presenting Problem/Diagnosis:

© VirginiaLong-TermCareCouncd,1994

UAl Part A 1

I CLIENTNAME:

ClientSSN:

-

No 0 Yes 1

CheckAll

Servzces That Apply

Provider/Frequency:

 

Adu]t

Day

Care

 

 

 

 

Adult

Protective

 

 

 

 

Case Management

 

 

 

 

Chore/Companion/Homemaker

 

 

 

Congregate

 

Meals

/ Senior

Center

 

 

Financial

Management/Counseling

 

 

Friendly

Visitor/Telephone

Reassurance

 

 

Habfiltatlon/Supported

Employment

 

 

Home

Delivered

Meals

 

 

 

Home

Health/Rehabilitation

 

 

 

Home

Repalrs/Weatherizatlon

 

 

Housing

 

 

 

 

 

 

Legal

 

 

 

 

 

 

 

Mental Health (Inpatient/Outpatient)

 

 

Mental

Retardation

 

 

 

 

Personal

Care

 

 

 

 

Respite

 

 

 

 

 

 

 

Substance

 

Abuse

 

 

 

Transportation

Vocational Rehab/Job Counseling

Other

$20,000or More ($1,667orMore)0

 

No 0

Yes 1

 

 

 

 

 

Names

$15,000 - $19,999 ($1,250 - $1,666) 1

 

 

Legal

Guardian,

 

 

 

$11,000 - $14,999 ($

917-

$1,249)

2

 

 

Power

of

Attorney,

 

 

$ 9,500 - $10,999 ($

792

- $

916)

3

 

 

Representative

Payee,

 

 

$

7,000-$

9,499($

583-

$

791)4

 

 

 

Other,

 

 

 

 

 

 

$

5,500-$

 

6,999($

458-$

582)

5

 

 

 

 

 

 

 

 

 

$

5,499 or

Less

($

457

or

Less)

6

 

Do your4_q_ve anybenefi_

_fifi_?

 

 

Unknown9

 

 

 

 

 

 

No 0

Yes1

 

 

 

 

 

 

Numberin Familyunit.

 

 

 

 

 

 

AuxiliaryGrant

 

 

Optional.

Total monthly farmly income

 

 

 

 

Food

Stamps

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fuel

Assistance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

General

Relief

 

 

 

DO yOU

currently receive

income

from.,.

?

 

State

and

Local

Hospltahzatlon

No 0 Yes 1

 

 

 

 

 

Optwnal

Amount

 

Subsidized

Housing

 

 

 

Black Lung,

 

 

 

 

 

 

Tax Relief

 

 

 

 

 

Pension,

 

 

 

 

 

V_/hat

ty-pes of headth

insurance

do

you

have?

 

Social

Security,

 

 

 

 

 

 

 

 

 

 

 

 

 

SSI/SSDI,

 

 

 

 

 

No 0

Yes

 

 

 

 

 

 

 

VA Benefits,

 

 

 

 

 

 

Medicare,

 

#

 

 

 

 

Wages/Salary,

 

 

 

 

 

 

Medicaid,

 

#

 

 

 

 

Other,

 

 

 

 

 

 

 

Pending

 

_ No

0 _1

Yes

QMB/SLMB

[] No 0 []

Yes

All Other Public/Private

 

© Virginia Long-Term Care Councfi, 1994

 

UA1 Part A 2

CLIENTNAME:

ClientSSN:

-

Where do you usually live? Does anyone live with you?

Alone 1

Spouse 2

Other 3

Names of Persons in Household

HouseOwn0

House Rent 1

House Other 2

i

Apartment 3

Rented Room 4

 

 

Name of Provider

Admission

Provider Number

 

 

(Place)

Date

(IfApphcable)

AdultCareResldence50

 

I

Adult Foster

60

 

 

Nursing

Facfilty 70

 

 

Mental

Health/

 

 

Retardation

Facility 80

 

 

 

 

 

 

I

Other

90

 

 

l

 

 

 

No 0 Yes l

Check All Problems That Apply

Describe

Problems:

Barriers to Access

Electrical Hazards

Fire Hazards/No Smoke Alarm

Insufficient Heat/Air Conditioning

Insufficient Hot Water/Water

Lack of/Poor Toilet Facilities (Inside/Outside)

Lack of/Defective Stove, Refrigerator, Freezer

Lack of/Defective Washer/Dryer

Lack of/Poor Bathing Faclhtles

Structural Problems

Telephone Not Accessible

Unsafe Neighborhood

Unsafe/Poor Lighting

Unsanitary Conditions

Other:

© VirginiaLong-TermCareCouncil,1994

UAI Part A 3

I CI'.IENTNAME:

ClientSSN:

-

PHYSICAL HEALTH ASSESSMENT

 

 

 

I

 

Doctor's Name_s)

(L_st all)

Phone

Date of Last Visit

Reason for Last Visit

Admissions.- In the past i2 months, have you been admired to a ,.. for medical or rehabfiitation reasons?

 

 

Admit

 

No 0 Yes 1

Name of Place

Date

Length of Stay/Reason

Hospital

 

 

 

NursingFacility

 

!

 

Adult Care Residence

 

 

 

Do

you have any advanced directives such as... (Who has it.., Where is it..,

)?

No0

YesI

Locatwn

 

Living Wdl,

 

 

Durable Power of Attorney for Health Care,

 

 

Other,

 

;?_,y(m

have

any current medical

problems,

or a _or

_i_tearl

_i_,_

_

meltial

 

 

 

D'_osem

 

 

 

_lr_dation

or related

conditmns,

such as,**

(Refer

to the

llst of diagnoses_

 

 

 

 

 

: _

'__0_

!'roMt,m_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

slooa -R_

 

 

 

CurrentDiagnoses

 

 

 

 

 

DateofOnset

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cat_1_tar_ulat_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C_reulattca_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H_a't_nml_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i

 

 

 

 

Enter Codes for

3 Major,

Active Diagnoses:

__

None 00 __

DX1

__

DX2

__

 

DX3

 

Au_ismlt_

 

 

 

 

Current Medications

 

Dose, Frequency,

Route

 

Reason(s) Prescribed

 

 

 

Elvlk'P_i_

 

 

 

(IncludeOver-the-Counter)

 

 

 

 

 

 

 

 

 

 

 

_i_Ataltat

¢f_

.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__._

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_l_ac,

 

cal_

tt_

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_ulo_a_na_

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Er._

 

;n) '

 

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lmmu_ S_

Dl_a*a_*s

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_hat,

 

tal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Azhkrttlsl

.Rlmmna_d A.*flu4tis

7.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Osmoporosi_sa0

eaaaemsc2_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ot_l_luKtaatt_l

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N_roIo_i_t_bbmu

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Brain Tra_n_/_

126)

 

9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stroke_

 

 

10.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OtherNatr_Pr_lems

tz_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychia_rki_al_m

 

Total

No. of Medications:

--

(If 0, skip to Sensory

Function) Total

No. of Tranquilizer/Psychotropic

Drugs:

--

 

 

Anxiety Diaord_rO0)s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bipolar

(3D

.,

 

Do

you

have any p_oblems

with

medicine(s).

?

How

do you take your medicine(s)?

 

 

 

 

P_r_

_m_

 

No 0

Yes1

 

 

 

 

 

 

W_thoutassistance0

 

 

 

 

 

Psyckla feProblemTs35)

 

 

 

 

 

 

 

 

 

 

R_pir_ _b_m

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adw_'rse reactions/allergies

 

 

Admm_stered/momtored

by lay person

1

 

__

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COPD_3_

 

 

 

 

 

 

Cost of me&cat_on

 

 

 

Admm_stered/momtored

by professional

 

 

P_m)

 

 

 

 

 

 

Gettmg

to the

pharmacy

 

 

nursing

staff 2

 

 

 

 

 

 

ot_s__09_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ttsri_!m_twav_ l'r_

Taking

CLIENT NAME:Client SSN:]

iiiiiiiiiiiiiii i ii i

iii! iiii!

ili

i ii!iiiiiiiiiiiiiiiii!i!iiiiiiii

 

 

 

No Impairment

0

 

 

Impairment

Complete Loss 3

Date of Last Exam

 

 

 

Record Date

of Onset/Type of Impairment

 

 

 

 

 

Compensation

1

No Compensation

2

 

Vision

 

 

 

 

 

 

 

Hearing

 

 

 

 

 

 

 

Speech

 

 

 

 

 

i

 

Within normal limits or instability corrected 0

 

 

 

Limited

motion 1

 

 

 

 

Instability uncorrected or immobile 2

 

 

 

 

:::::.::. :;=.I

I

I III:

I

II

I

I

_,

Fractures/Dislocations

Missing Limbs

 

Paralysis/Paresis

None000

 

None000

__

None000

 

Hip

Fracture

1

Finger(s)/Toe(s) 1

__

Partial 1

 

OtherBrokenBone(s)2

Arm(s)2

__

Total2

 

Dislocation(s)3

Leg(s)3

Describe:

 

Combination4

Combination4

 

 

 

Previous

Rehab Program?

Previous Rehab Program?

Previous Rehab

Program?

No/Not Completed 1

No/Not Completed ]

__

No/Not Completed ]

Yes2

 

 

Yes2

__ Yes2

 

Date of Fracture/Dislocation?

Date of Amputation?

Onset

of Paralysis?

1Yearor Less1

1YearorLess1

 

1YearorLess

Morethan 1Year2

Morethan 1Year2

__

Morethan 1Year2

Height:

Weight:

Recent Weight Gain/Loss:

No 0 __ Yes

(inches)

 

(lbs.)

 

 

 

Describe:

 

None0

 

No0 Yes1

 

Low Fat/Cholesterol

]

Food Allergies

 

No/Low

Salt 2

 

 

Inadequate

Food/Fluid

Intake

No/Low

Sugar

3

 

Nausea/Vomiting/Diarrhea

 

Combination/Other

4

Problems

Eating Certain

Foods

 

 

 

 

Problems

Following Special Diets

None0

 

 

 

ProblemsSwallowing

Occasionally1

 

TasteProblems

 

Daily, Not Primary

Source 2

Tooth or

Mouth Problems

Daily, Primary

Source 3

Other:

 

 

Daily, Sole Source 4

 

 

 

 

© Virginia Long-Term Care Council, 1994

 

 

UA1 Part B 6

'! C IENTNAME

C,ientSSN: I

iiiiiiiiii

i_ii_

i

i!iiii!iiii!¸¸

iiiiii!ii!i

_i_i_!_i_i_i!ii!!i_i_ii_iiiii!!_i_!i!ii_!i_!

No 0 Yes 1

Frequency

No 0 Yes 1

Occupational

Physical

Reality/Remotivation

Respiratory

Speech

Other

None

0

Location/Size

Stage

I

1

Stage

II 2

StageIII3

StageIV4

Based on client's overall condition, assessor should evaluate medical and/or nursing needs.

__ No 0 __ Yes 1

If yes, describe ongoing medical/nursing needs:

1.Evidence of medical instability.

2.Need for observation/assessment to prevent destabilization.

3.Complexity created by multiple medical conditions.

4.Why client's condition requires a physician, RN, or trained nurse's aide to oversee

Comments:

Site, Type, Frequency

Bowel/Bladder Training

Dialysis

Dressing/Wound Care

Eyecare

Glucose/Blood Sugar

Injections/IV Therapy

Radiation/Chemotherapy

Restraints (Physical/Chemical)

ROM Exercise

Trach Care/Suctioning

Ventilator

Other:

care on a daily basis.

Optional:

Physician's

Signature:

Date:

 

 

Others:

Date:

 

 

 

(Signature / Title)

(_ Virginia

Long-Term

Care Council, 1994

UAI Part B 7

CLIENTNAME:

ClientSSN:

I

PSYCHO- SOCIAL ASSESSMENT

Orientation (Note: Information in italics is optional and can be used to give a MMSE Score in the box to the right.)

Oriented0

Spheresaffected:

Disoriented - Some spheres, some of the time 1

Disoriented - Some spheres, all the time 2

Disoriented - All spheres, some of the time 3

Disoriented - All spheres, all of the time 4

Comatose 5

Recall/Memory/Judgement

No 0 Yes I

Short -Term Memory Loss?

Long-Term Memory Loss?

Judgement Problem?

i _ _iii_ilEii!iiiiiii_iiiii??iiii!iiiiiiii?Z:* iiii ii!iiiiiiili!ii_iiiiii!ili!iiiii!ilili!i!iiiiiiiiiiiiiii!iiiiiiii?iiiii!i: : [ : iiiiii?i!i!ii_i_i_i_i_i!?_ii_i!?_i_i!ii_!_i_!ii_ii?_i?_!_!_i_i_i_i_i_i!i_i_i_iii_i?_?_i_!_ii?ii_i!i

Appropriate

0

 

 

 

 

Wandering/Passive

- Less than weekly 1

 

Wandering/Passive

- Weekly or more

2

 

Abusive/Aggressive/Disruptive

- Less

than weekly

3

Abusive/Aggressive/Disruptive

- Weekly or more

4

Comatose

5

 

 

 

 

Typeof inappropriate behavior:

 

 

Sourceof Information:

No0 YesI

 

No0 Yes1

No0 Yesl

 

Change

in work/employment

Financial problems

Victim

of a crime

Death

of someone close

Major illness - family/friend

Failing

health

Family

conflict

Recent move/relocation

Other:

 

© Virginia Long-Term Care Council, 1994

 

 

UAI Part B 8

CLIENTNAME:

ClientSSN:

 

 

 

 

 

 

 

 

Rarely/

Some of

Often 2

Most of

Unable to

l

 

 

 

 

 

 

 

 

Never0

theTime 1

 

theTime3

Assess9

 

Feel anxious or worry constantly about things?

 

 

 

 

 

 

 

Feel irritable, have crying spells or get upset over little things?

 

 

 

 

 

Feel alone and that you didn't have anyone to talk to?

 

 

 

 

 

 

 

Feel like you didn't want to be around other people?

 

 

 

 

 

 

 

Feel afraid that something bad was going to happen to you

 

 

 

 

 

 

and/or feel that others were trying to take things from you

 

 

 

 

 

 

or trying to harm you?

 

 

 

 

 

 

 

 

 

 

Feel

sad

or hopeless?

 

 

 

 

 

 

 

 

 

 

Feel

that

life is not worth

living..,

or think

of taking

your

life?

 

 

 

 

 

See or hear things that other people did not see or hear?

 

 

 

 

 

 

Believe that you have special powers that others do not have?

 

 

 

 

 

Have problems

falling or staying asleep?

 

 

 

 

 

 

 

 

Have

problems

with your

appetite..,

that

is, eat too

much

or

 

 

 

 

 

toolittle?

 

 

 

 

 

 

 

I

 

 

 

Comments:

No0 Yes1

Describe

Solitary Activities,

With Friends/Family,

With Groups/Clubs,

Religious Activities,

Children

Other Family

Friends/Neighbors

 

No Children 0

No Other Family 0

No Friends/Neighbors

0

Daily1

Daily_

Daily

 

Weekly2

Weekly2

Weekly2

 

Monthly3

Monthly3

Monthly3

 

Less than Monthly 4

Less than Monthly 4

Less than Monthly 4

 

Never5

Never5

Never5

 

No 0

Yes 1

 

 

(_) Virginia Long-Term

Care Council, 1994

UA1 Part g

9

I CLIENT

NAME-'

Client SSN:

-

ii!iliiiii _iii_iiiiiiiiiiiiiiiiii__iiiiiiiiiiiiii!iiii!1!iiiii _i_iigiiiiiiiiiiiiigiiiiiiiiiiiii!iiiiiiiiiiiiiiiiiii2i__iiiiiiiiiiiiiiiiiiiii_iiiziz_iziii_ii__iiii___i_i_i__iii_iigii_iiiiiiiii_i

I CLIENTNAME:ClientSSN:

ASSESSMENT

SUMMARY

Indicators of Adult Abuse

and Neglect: While completing the assessment, if you suspect abuse, neglect or exploitation, you are

required by Virginia law, Section 63.1 - 55.3 to report this to the local Department of Social Services, Adult Protective Services.

No 0 (Skip to Section on Preferences)

Yes l

With client 0

Separate residence, close proximity 1

Separate residence, over 1 hour away 2

Adequate to meet the client's needs? 0

Not adequate to meet the client's needs? 1

Not at all 0

Somewhat 1

Very much 2

Client's preferences for receiving needed care:

Family/Representative's preferences for client's care:

Physician's comments (if applicable):

© Virginia Long-Term Care Council, 1994

UAI Part B 11

CLIENT NAME:

Client SSN:

-

I

No 0 Yes 1 (CheckAll That Apply)

No 0 Yes 1 (CheckAll That Apply)

 

Finances

 

Assistive

Devices/Medical

Equipment

Home/Physical

Environment

Medical

Care/Health

 

ADLS

 

Nutrition

 

IADLS

 

Cognitive/Emotional

 

 

 

Caregiver

Support

 

Assessor's Name

Signature

Agency/Provider

Name

Provider#

Section(s)

 

 

 

 

 

Completed

Optional:

Case assigned to:

Code #:

© Virginia

Long-Term Care Council, 1994

UAI Part B 12