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Functional Assessment Patient's Name:_____________________________________ Date: _________________ Date of Birth:_________________ Current Living Arrangements: _____________________________________________________ Relationship to Applicant/Person completing This Form: _____________________________________________________ Patient 's Medical Diagnoses: _____________________________________________________ For each area of functioning listed below, please describe to the best of your ability the amount and type of assistance the applicant requires. BATHING Does patient take a shower, tub bath or sponge bath? _____________________________________________________ How often does he/she bathe? _____________________________________________________ How much assistance is needed? _____________________________________________________ DRESSING How much assistance does patient receive in dressing (including selecting and getting clothes from closet, putting on undergarments and using fasteners)? _____________________________________________________ Additional Comments _____________________________________________________ TOILETING Does patient require assistance with toileting (including getting to and from bathroom, cleaning self after elimination and arranging clothes)? _____________________________________________________ If yes, how much assistance is needed? _____________________________________________________ Does patient have a catheter? What type? _____________________________________________________ Does he/she have a colostomy? _____________________________________________________ Is patient able to control urination?____________ Bowel movements? _____________________________________________________ If no, how often do "accidents" occur? _____________________________________________________ MOBILITY Does patient walk (list assistive devices used, i.e., walker, cane) or does he/she use a wheelchair? _____________________________________________________ Does he/she need assistance getting out of bed or a chair? _____________________________________________________ If yes, how much assistance is needed? _____________________________________________________ EATING Does patient feed self or require assistance eating? _____________________________________________________ Does he/she use adaptive equipment while eating (i.e., plate guard, special spoon, etc.)? _____________________________________________________ Is he/she on a special diet? _____________________________________________________ How would you describe patient's appetite? _____________________________________________________ Height_______________________________ Weight_______________________________ MEDICATION List patient's current medications: _____________________________________________________ Any known drug allergies? _____________________________________________________ Is patient using oxygen (if yes, how much and how often)? _____________________________________________________ PROSTHESES Does patient have an arm or leg prosthesis? _____________________________________________________ Does he/she wear dentures (upper and lower)? _____________________________________________________ Does he/she use a hearing aide? _____________________________________________________ SKIN Does patient presently have bed sores (if yes, where and for how long)? _____________________________________________________ Does he/she have skin rashes? _____________________________________________________ Does he/she experience swelling of the legs or feet? _____________________________________________________ ORIENTATION Is patient alert and oriented or does he/she exhibit confusion? (If confused, is it ongoing, often, or occasional?) _____________________________________________________ For individuals who are confused and disoriented: Does the patient attempt to wander? _____________________________________________________ If yes, how often? _____________________________________________________ Is he or she willing to return if given direction? _____________________________________________________ OTHER HEALTH CONSIDERATIONS Does patient currently use physical or chemical restraints? If yes, describe type and frequency: _____________________________________________________ Has he/she ever been hospitalized for any other health problems? If yes, state when, where, and why: _____________________________________________________ Does patient maintain active and satisfying relationships with family and friends? _____________________________________________________ Does he/she have a history of drug or alcohol abuse? If yes, please describe: _____________________________________________________ Is patient currently receiving physical, occupational, speech, or respiratory therapy? If yes, list type of therapy, reason for, and frequency received: _____________________________________________________ Additional Comments: _____________________________________________________ |