• AFL Care Plan - Initial Assessment

  • *Did you collect a signed arbitration agreement in the direct care provider's preferred language?*

  • Participant Information

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender:*
  • Start of Service
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: +1 (000) 000-0000.

  • Contact Information

  • Format: +1 (000) 000-0000.
  • Format: +1 (000) 000-0000.
  • Format: +1 (000) 000-0000.
  • Format: +1 (000) 000-0000.
  • Format: +1 (000) 000-0000.

  • Care Plan

  • Care Plan Strategies

    Daily Living Activity
  • Positioning in bed - Help Needed:
  • Positioning in bed - Equipment Used:

  • Care Plan Strategies

    Moving- transferring to/from bed, car
  • Moving- transferring to/from bed, car, chair etc. - Help Needed:
  • Moving- transferring to/from bed, car- Equipment Used:

  • Care Plan Strategies

    Walking/Ambulation
  • Walking/ Ambulation -Help Needed- INDOOR
  • Walking/ Ambulation - Help Needed-OUTDOOR
  • Walking/ Ambulation-Equipment Used

  • Care Plan Strategies

    Getting Dressed
  • Getting Dressed-Help Needed - UPPER BODY
  • Getting Dressed-Help Needed - LOWER BODY
  • Getting Dressed-Equipment Used

  • Care Plan Strategies Cont.

    Daily Living Activity
  • Eating & Drinking- Help Needed
  • Eating & Drinking-Equipment Used

  • Care Plan Strategies Cont.

    Using the toilet
  • Using the toilet- Help Needed
  • Using the toilet- Particpant has
  • Using the toilet - Equipment Used

  • Care Plan Strategies Cont.

    Bathing/ Showering
  • Bathing/ Showering- Help Needed
  • Bathing/ Showering- Equipment Used

  • Care Plan Strategies Cont.

    Washing up, brushing teeth, hair
  • Washing up, brushing teeth, hair- Help Needed

  • Care Plan Strategies Cont.

    Preparing meals
  • Preparing meals- Help Needed

  • Care Plan Strategies Cont.

    Doing light housework
  • Doing light housework- Help Needed

  • Care Plan Strategies Cont.

    Transportation
  • Transportation- Help Needed*
  • Transportation- Equipment Used*
  • You selected that the CG/Family transports the client. Did you collect their Driver's License and Car Insurance Information?*

  • Care Plan Strategies Cont.

    Finances
  • Finances- Help Needed
  • Finances - Equipment Used

  • Care Plan Strategies Cont.

    Phone Use
  • Phone Use- Help Needed
  • Phone Use- Equipment Used

  • Care Plan Strategies Cont.

    Shopping
  • Shopping- Help Needed

  • Care Plan Strategies Cont.

    Other-Fall, Risks, and Safety
  • Fall, Risks, and Safety- Help Needed
  • Fall, Risks, and Safety- Equipment Used
  • Fall, Risks, and Safety- Equipment Used

  • Care Plan Strategies Cont.

    Other-Medication Preparation/Organization
  • Medication Preparation/Organization- Help Needed
  • Medication Preparation/Organization- Equipment Used

  • Care Plan Strategies Cont.

    Sensory and Communication-Vision
  • Vision- Performance
  • Vision- Equipment Used

  • Care Plan Strategies Cont.

    Sensory and Communication-Hearing
  • Hearing- Performance
  • Hearing- Equipment Used-Wears hearing aid:
  • Hearing- Equipment Used-Wears hearing aid:

  • Care Plan Strategies Cont.

    Sensory and Communication-Communication
  • Communication- Performance
  • Communication- Equipment Used

  • Care Plan Strategies Cont.

    Sensory and Communication-Pain
  • Pain- Performance-Pain Frequency
  • Pain- Performance-Usual Pain Level (Self-Report)
  • Pain- Performance-Pain Control is:
  • Pain- Performance-Pain - Other:
  • Pain- Equipment Used

  • Care Plan Strategies Cont.

    Nutrition Status-Meal Intake
  • Meal Intake- Performance

  • Care Plan Strategies Cont.

    Nutrition Status-Output
  • Output- Performance

  • Care Plan Strategies Cont.

    Cognitive Status
  • Cognitive Status
  • Cognitive Status-Alert, Oriented, Confused, Some Confusion, Non-Alert or Oriented- Performance

  • Care Plan Strategies Cont.

    Health Conditions / Behavioral Situations that Require Extra Attention
  • Who Manages?*

  • Care Plan Strategies Cont.

    Health Conditions / Behavioral Situations that Require Extra Attention
  • Who Manages?

  • Care Plan Strategies Cont.

    Health Conditions / Behavioral Situations that Require Extra Attention
  • Who Manages?

  • Care Plan Strategies Cont.

    Medical Treatments and Equipment-Tratments
  • Treatments-Services, Equipment, etc.

  • Care Plan Strategies Cont.

    Medical Treatments and Equipment-Equipment Management
  • Equipment Management-Services, Equipment, etc.
  • Cares for equipment as directed:

  • Care Plan Strategies Cont.

    Home & Community Program(s) and Services
  • Home & Community Program(s) and Services -Services, Equipment, etc.
  • Physical Therapy*
  • Occupational Therapy:*

  • Care Plan Strategies Cont.

    Home & Environment Checklist
  • Emergency Planning-Service Details *
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

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