GOVERNOR'S OFFICE OF ELDERLY AFFAIRS

Client's Initials

Louisiana Independent Living Assessment (LILA) Statewide Comprehensive Needs Assessment Form

Assessment Date

Date

Re Assessment Date

Date

Veteran:

Veteran Dependent:

First Name

Middle Name

Does the Client wish to be evacuated in case of a disaster?

Last Name

Client Suffix

Client Maiden Name

Client AKA Name

Marital Status:

Gender:

Date of Birth

Date

Age

COA Membership Card Declined Accepted

Accepted

Declined

Client's ID: Last 4 of Client's SS #:

Last 4 of Client's SS #

Client's ID

Phone Number

Cell Number:

Client's Mailing Address (if same write SAME):

Street

P.O. Box

Town

State

Zip Code

State

Zip Code_

Other (Individual ($12,060 FY/2017)

Monthly Poverty Guideline per Person: Monthly 1-$1,005 or less 4-$2,050 or less Income: 2-$1,353 or less5-$2,398 or less 3-$1,702 or less 6-$2,747 or less

Household Size:

Medicaid Policy #

Monthly Household Income:

Monthly Individual Income:

Medicare #

Insurance Medicaid:

Medical Assistance ID #

Client's Initials

Ethnicity:

In Poverty:

Lives Alone:

Is Rural:

High Nutrition Risk:

NSIP Meal Eligible:

From Page 4. Nutrition Score:

ADL Score:

LADL Score:

Eligibility Type: Age 60 or over

Disabled in Elderly Housing

Disabled living with Elderly Person

Food Handlers

Guest/ Staff under 60

I & R Clients

Not indicated

Other

Spouse

Tribal Age Specification

Volunteer

State Resident

Duplicate Mail:

Abuse/ Neglected/ Exploited:

Female Head of Huse-hold:

Tribal

Understand English:

U.S. Citizen:

Medicare Eligible:

Cognitive Impairment:

Employment Status:

Receiving Social Security:

Disabled:

Frail:

Homebound

Language:

Race

Name Emergency Contact

First NameLast Name

Address emergency Contact

Phone Number Emergency Contact

Please enter a valid phone number.Format: (000) 000-0000.

Directions to Client's Home:

Relative / Friend

First NameLast Name

Address of Relative / Friend

Phone Number Friend / Relative

Please enter a valid phone number.Format: (000) 000-0000.

Cell Number Friend / relative

Please enter a valid phone number.Format: (000) 000-0000.

Relationship

Do you have prescription drug insurance?

The client formally authorized release of information. Copy of signed and dated authorization is attached to this assessment

List all the services the client will receive:

Client has been advised that he/she has an opportunity to make volu ntary and anonymous donations for any service they may receive and has received a copy of policy.

Where did Assesment take place

Client signature

Date

Signature - Assessor

Date

Where did reassessment take place

SIGNATURE Client

Date

Signature- Assessor

Date

Nutrition Health Risk (Tally up answers)

Yes No

• Has the client made any changes in lifelong eating habits because of health problems?	2	0
• Does the client eat fewer than two meals per day?	3	0
• Does the client eat fewer than five servings (1/2 cup each) of fruits and vegetables?	1	0
• Does the client eat fewer than two servings of dairy products (such as milk, yogurt, or cheese) every day?	1	0
• Does the client sometimes have enough money to sometimes buy food?	4	0
• Does the client have biting, chewing, or swallowing problems that make it difficult to eat?	2	0
• Does the client eat alone most of the time?	1	0
Has the client lost or gained ten pounds in the past six months without wanting to?	2	0
• Is the client able to shop, cook, and /or feed themselves (or get someone to do it for them)?	0	2
• Does the client have three (3) or more drinks of beer, liquor, or wine almost everyday?	2	0
• Does the client take three (3) or more prescriptions of over-the-counter drugs daily?	1	0

Combined total (Add YES + NO for your total nutrition score)

If. Score is:

0-2 GOOD! Recheck the Nutritional Score in 6 months.

3-5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyles. Your area agency on aging, senior nutrition program, senior citizens center or health department can help. Recheck your Nutritional Score in 3 mo.

6 or more You are at high nutritional rick. Bring a copy of this checklist the next time you see your doctor, dietitian, or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.

(Be sure to put all three score totals on second page of assessment)

__________________________________________________________________

Can You	Yes	NO		Yes	No	Yes	No	Comment
a) Get around inside your home			ADL
b) Bathe			ADL
c) Dress			ADL
d) Get in and out of bed/chair			ADL
e) Use toilet			ADL
f) Eat			ADL
g) Groom yourself			ADL
h) Manage your money			IADL
i) Do laundry			IADL
j) Take care of shopping			IADL
k)Take your medication			IADL
l) Prepare your meals			IADL
m)Perform heavy home chores			IADL
n)Perform ordinary housework			IADL
o)Take out garbage			IADL
p) Use transportation			IADL
q) Use telephone			IADL

Total ADL Type a label IADL Type a label record the total number of "NO without help" for ADL and IASDL score.

Where was the client interviewed?

Name of the person that helps the client?

Name of the agency where assessor works?

Describe where the client was interviewed

What is the helper's relationship to the client?

Did someone help the client or answer question for the client?

What is the name of the person conducting this assessment?

Was communication/ language assistance needed for this assessment?

What type of communication / language assistance was needed for this assessment?

Does the client have a power of attorney?

Does the client have a legal guardian?

What is the name of the client's power of attorney?

What is the name of the client's guardian?

Phone number of client's power of attorney

Please enter a valid phone number.Format: (000) 000-0000.

Dose client having living will?

If the client does not have a living will, was information provided about advanced directives?

What is the client's main problem or reason for referral (when not a standard choice)

Type a question

Who was the client referred by?

Indicate the type if residence that the client currently resides:

Select the client's Living arrangement

What is the name of the Client's spouse/partner?

Dose the client have any children?

Does the client have contact with family often enough?

Does the client have contact with friends often enough?

Is there a friend or relative that could take care of the client for a few days?

How does the client rate his/her health?

Is the client limited in what s/he can do because of the stroke/ neurological condition?

How often does bad health, sickness, pain, or disability stop the client from doing things s/he would like to do?

In a typical week, during the last 30 days, how often did the client go outside of their residence (no matter for how short period of time)?

What is the name of the agency that referred the client?

Who referred the client?

Client's Initials

Indicate which of the following conditions/diagnoses the client currently has.

When the client makes a decision about something how does s/he do it?

What was the client's response when asked. "what year is it?"

What was the client's response when asked, "what month is it?"

What was the client's response when asked. "Where are you now?"

Has the client fallen in the past three months?

Does the client use a walker to get around?

Does the client use a wheelchair to get around?

Does the client have problems with hearing that are not corrected with aids/device?

Describe the aids/devices used by the client to correct hearing problems.

Are the client's hearing aids/devices in working order?

Does the client have problems with vision that are not corrected with aids/devices?

Describe the aids/devices used by the client to correct vision problems.

Are the client's vision aids/devices in working order?

Does client have problems with speech that are correct with aids/devices?

Describe the aids/devices used by the client to correct speech problems.

Are the client's speech aids/devices in working order?

Does the client often feel sad or blue?

Client's Initials

How many precription medications does the client take?

Is the Client participating in any of the following services or programs?

Does the client want to apply for any of the following services or programs?

Client's Initials

Client NAME:

Client ID#

Date

Nutritional Store (page 4):

Services Requested:

Is this person low income? Yes= 1 No= 0

Is this person a minority? Yes= 1. No= 0

Is this person living alone? Yes= 1. No= 0

What is the person's ADL count from page 4 (score 0-6)?

What is the person's IADL count from page 4 (score 0-6)?

Is the person residing n a rual area? Yes=1. No=0

What age is the person? Below 75=0. 75-84=1 85+=2

What level of support is currently available to this person?High=0 Moderate=1 Very little or none=2

Is the person on a special diet? Yes=1. No=0

Is the person homebound? Yes=1 No=0

Total (tally the previous 10 answers)

Medication Name answer here Primary diagnosis type here directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label

Medication Name Type a label Primary diagnosis Type a label directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label

Medication Name Type a label Primary Type a label diagnosis directions/strength/ & dosage. Type a label Prescribing Doctor & Phone Type a label Manufacture & Cost Type a label

Do you have problems or difficulty remembering to take your medications? (select yes or no.). (If necessary, prompt the client by asking is s/he is concerned and forgetting. What steps does s/he take to remember?). [fill out in blank below]

Other

Please list your drug allergies:

Referral Made:

Client's Initials

Date

I Name Address Type a label .

I acknowledge that I have received a Grievance Form for the:

Signature

Client's Initials

Name

First NameLast Name

Authorize the release of information contained in the Louisiana Assessment (LILA) form to other agencies or entities to deternie eligbility for services.

Signature

Date

Witness

Client Name

ID #

DOB

Date

Age

COMMUNICATIONS WITH CAAREGIVERS AND RELATIVES We may use or disclose your information to notify or assist in notifying: (1) a family member, personal represenaative, or caregiver reguarding your location and general condituon; (2) a family member, other relative, close personaal friend, or any other person you authorize, as necessary for and directly relevant to that person's involvmnet in your care. Please sign and authorized person below:

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Signature

Date

Rapides Council on Aging

204 Chester Street

Alexandria, LA 71301

(318) 445-7985