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.
Physician Phone Number
Please enter a valid phone number.
Responsible Party Phone Number
Please enter a valid phone number.
Emergency Contact Phone Number
Please enter a valid phone number.
Assessment Details

Health, current situation, and general information.
Current Medications (list all)
Need for Palliative Care

YesNo
Dental Care Needs

YesNo
Vision Care Needs

YesNo
Hearing Care Needs

YesNo
Smoking Habits

YesNo
If consumer smokes, is there an issue/problem?

YesNo
Alcohol Consumption

YesNo
If consumer drinks, is there an issue/problem?

YesNo
Current Situation / Recent Hospitalizations or Health Problems
Height (inches or cm)
Weight (lbs or kg)
Weight Status

IncreaseStaticDecrease
Recent Weight Changes (describe)
Alertness

AlertOrientedConfusedDisorientedOther
Memory

IntactPoor
Reasoning/Judgment

GoodPoorUnimpaired
Mental Health Status
Special Dietary Requirements

NoYes (explain)
Allergies

NoYes (specify)
Eating Habits
Appetite

GoodFairPoor
Primary Language
Speaks/Understands English

YesNo
Can make needs known

YesNo
Communication Ability

UnimpairedUnderstands Simple Phrases OnlyUnderstands Key Words OnlyUnderstanding UnknownNot Responsive
Activities of Daily Living

Assess ability to perform daily living activities.
Bathing

IndependentIndependent with Mechanical AidsRequires Minor Assistance or SupervisionRequires Continued AssistanceResists Assistance
Grooming & Hygiene

IndependentSupervision or Needs some occasional assistPeriodic or Daily Assist NeededRequires Total AssistanceResists Assistance
Dressing

IndependentIndependent with Special Provision for DisabilityIntermittent Assist WithResists Feeding
Eating

Totally ContinentNeeds Routine Toileting or ReminderIncontinent occasionallyIncontinent dailyCutting Up/Pureeing FoodMust Be Fed
Functional Limitations (describe)
Mobility

IndependentUnableNeeds assist
Ambulation

IndependentUnableNeeds assist
Transfers

IndependentUnableNeeds assist
Bladder Control

Totally ContinentNeeds Routine Toileting or ReminderIncontinent occasionallyIncontinent daily
Bowel Control

Total ControlNeeds Routine Toileting or ReminderNo Bowel Control Due to Identifiable FactorsLoses Bowel Control occasionallyLoses Bowel Control daily
Instrumental Activities of Daily Living

Assess ability to perform instrumental activities.
Toileting

IndependentNeeds Help with Aids (e.g., Catheter, Condom Drainage)Other
Shopping

IndependentCan Shop if AccompaniedUnable to ShopNo Opportunity to Shop/Chooses Not to Shop
Meal Preparation

IndependentAble if Ingredients SuppliedCan Make/Buy MealsDiet is InadequatePhysically/Mentally Unable to Prepare FoodChooses Not to Prepare Food
Housekeeping

IndependentGenerally Independent But Needs Help With Heavier TasksNeeds Regular Help and/or SupervisionNo Opportunity to Do Housework/Chooses Not to Do Housework
Movement

IndependentCan Perform Only Light Tasks AdequatelyPerforms Light TasksPhysically or Mentally Unable to TravelNeeds Ambulance for Transporting
Transportation

Uses Private VehicleUses Taxi/BusMust be AccompaniedMust be Driven
Telephone Use

IndependentCan Dial Well Known NumbersAnswers OnlyUnableNo Opportunity to Use Telephone/Chooses Not to
Living Arrangements

AloneWith Spouse/PartnerWith Adult ChildWith Other Adult MaleWith Other Adult Female
Home Environmental Assessment
Any Safety/Health Hazards at Home?

YesNo
Social Profile

Information about social involvement, finances, and other factors impacting care.
Attendant Living Companions (select all that apply)

SpouseFriendFamilyNot met
Principal Helper

IndependentNeeds Attendant (Intermittent)Needs Attendant (24 hours)Needs Attendant (Daytime)Needs Attendant (Night)
Social Activities/Involvement (describe)
Religion
Actively Practicing Religion

YesNo
Ethnicity
Financial Benefits (select all that apply)

Social SecurityState Income SupplementCompany PensionOther PensionVeterans/DisabilityOther
Managing Finances

SelfSpouseFamilyFriendTrusteePower of AttorneyOther
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