Non-Medical Assessment Form

Non-Medical Assessment Form

Please complete this assessment to help us understand the consumer's needs and plan appropriate care.
Consumer Information

Basic details about the consumer and key contacts.
Consumer Full Name

First NameLast Name
Consumer Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Physician Name

First NameLast Name
Responsible Party Name

First NameLast Name
Emergency Contact Name

First NameLast Name
Consumer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Assessment Details

Health, current situation, and general information.
Current Medications (list all)
Need for Palliative Care
Dental Care Needs
Vision Care Needs
Hearing Care Needs
Smoking Habits
If consumer smokes, is there an issue/problem?
Alcohol Consumption
If consumer drinks, is there an issue/problem?
Current Situation / Recent Hospitalizations or Health Problems
Height (inches or cm)
Weight (lbs or kg)
Weight Status
Recent Weight Changes (describe)
Alertness

Other
Memory
Reasoning/Judgment
Mental Health Status
Special Dietary Requirements

Yes (explain)
Allergies

Yes (specify)
Eating Habits
Appetite
Primary Language
Speaks/Understands English
Can make needs known
Communication Ability
Activities of Daily Living

Assess ability to perform daily living activities.
Bathing
Grooming & Hygiene
Dressing
Eating
Functional Limitations (describe)
Mobility
Ambulation
Transfers
Bladder Control
Bowel Control
Instrumental Activities of Daily Living

Assess ability to perform instrumental activities.
Toileting

Other
Shopping
Meal Preparation
Housekeeping
Movement
Transportation
Telephone Use
Living Arrangements
Home Environmental Assessment
Any Safety/Health Hazards at Home?
Social Profile

Information about social involvement, finances, and other factors impacting care.
Attendant Living Companions (select all that apply)
Principal Helper
Social Activities/Involvement (describe)
Religion
Actively Practicing Religion
Ethnicity
Financial Benefits (select all that apply)

Other
Managing Finances

Other
Additional Information (any other info impacting care)
Assessment Signatures

Signatures required for assessment completion.
Assessor Name/Title (Print)
Assessment Date

MonthDayYear
Date
Assessor Signature
Client or Client’s Representative Name
Client or Client’s Representative Signature
Signature Date

MonthDayYear
Date
Should be Empty:

Non-Medical Assessment Form

Consumer Information

Assessment Details

Activities of Daily Living

Instrumental Activities of Daily Living

Social Profile

Assessment Signatures