Client Assessment Form

Name*

First NameLast Name

Birthdate*

MonthDayYear

Gender

Age

Height

Weight

Senior's Primary Diagnosis

Cognitive/Behavior*

Memory*

Oriented to NameOriented to PlaceKnows Month/Year

Short Term Memory*

Appears OkayMild LossModerate LossSevere Loss

Long Term Memory*

Appears OkayModerate LossMild LossSevere Loss

Mobility/Transfer*

Neurological*

Respiratory*

Cardiovascular*

Toileting*

Bedtime/Sleeping*

Feeding*

Bathing*

Grooming/Dressing*

Hearing*

AdequatePoorFair

Vision*

Diabetes*

Skin Care*

Urinary/Ostomy*

Other- Medical*

Other- Not Medical*

Current Medications

Any Dementia Behaviors

i.e. Sleep disturbances. Agitation, Delusions, Hallucinations

Senior's Marital Status*

MarriedNever MarriedDivorcedWidowed

Have Durable Power of Attorney for:

Healthcare (Advanced Health Care Directive)FinancialObtainingConservator

Responsible Party #1

Name, Address, Phone Number

Responsible Party #2

Name, Address, Phone Number

Senior's Veteran Status*

Not a VeteranWidow(er) of a VeteranVeteran -Discharged other than HonorableSpouse of a VeteranVeteran-Discharged Honorably or Under Honorable Conditions

Applied or in the process of applying for Veteran Aid & Attendance Benefit?

YesNoNeed AssistanceWhat is the Aid & Attendance Benefit?

Financial Information (Budget for Care)

SSI onlyLong Term Care InsuranceAdequate for Assisted Living ($4,000 - $10,000/month)Adequate for Room & Board ($1,000 - $3,000/month)

Senior's Social and Activity Interests

Type of TV shows they like, activities they like doing, ie gardening, knitting, board games, puzzles, etc...

Anything Else We Need to Know about the Senior

Client Assesment Form

Please fill out the following questions according to senior's current condition.