Clinical Assessment Questionnaire Long Form

Please complete the following questions to help with the assessment

Step 1 of 13

General Information

Please provide all contact information below

Care Recipient Name(Required)

Full Name

Primary Residence

Street Address City State / Province / Region ZIP / Postal Code

Phone

Home

Cell

Mobile

Date of Birth

Month

Day

Year

Please provide the day you were born

Marital Status

Single

Married

Divorced

Widowed

Please Choose One

Social Security # SSN

Please use email@email.com formatting

Emergency Contact

Please fill out Emergency Contact Information

Name

Full Name

Relation

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Home

Cell

Work Phone

Work

Primary Contact

Please fill out Primary Contact Information

Name

Full Name

Relation

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Home

Primary Contact Cell

Cell

Primary Contact Work Phone

Work

Primary Contact Email

Medical and Prescription Insurance Information

Please provide a copy of the front and back of all medical and prescription insurance cards

Primary Medical Insurance

Name of Insurance

ID#

Supplemental Medical Insurance

Name of Insurance

ID#

Grp#

Pharmacy Insurance

Name of Insurance

ID#

RX Information

RX BIN

RX PCN

RX GROUP

Upload Card Information

Drop files here or

Max. file size: 50 MB.

Upload front and back of medical and prescription insurance cards

Please Provide Your My Health Online Login Information

My Health Provider #1

Name of My Health Provider #1

Username

Password

My Health Provider #2

Name of My Health Provider #2

Username

Password

Durable Power of Attorney, POLST, and Advanced Health Care Directive

Please fill in form and upload copies of DPOA, POLST, and AHCD

Do you have a DOPA (Finance)?

Yes

Durable Power of Attorney (Finance)

Do you have a DOPA (Health)?

Yes

Physician Orders for Life-Sustaining Treatment

DPOA Health

Durable Power of Attorney (Health)

DPOA Finance

Name of the Durable Power of Attorney (Finance)

Do you have a POLST?

Yes

Physician Orders for Life-Sustaining Treatment

Advanced Health Care Directive?

Yes

Do you have a signed Advanced Health Care Directive?

DPOA, POLST, and Advanced Health Care Directive

Drop files here or

Max. file size: 50 MB.

Please upload copies of DPOA, POLST, and Advanced Health Care Directive

Physician Information

Please provide all your current health care providers information below

Primary Physician

Name

Primary Physician Phone

Primary Physician Fax

Address

Street Address City State / Province / Region ZIP / Postal Code

Last visit date

MM slash DD slash YYYY

Reason

Reason for the visit

Dentist Information

Dentist Name

Name

Dental Insurance

Dentist Address

Street Address City State / Province / Region ZIP / Postal Code

Dentist Phone

Phone Number

Dentist Fax

Fax Number

Specialty Doctor Information

Please provide any specialty doctor information below

Specialty Doctors Name #1

Specialty 1

What is specialty of doctor #1

Specialty Doctors Address #1

Street Address City State / Province / Region ZIP / Postal Code

Phone

Specialty Doctors Name #1 Phone

Fax

Specialty Doctors Name #1 Fax

Specialty Doctors Name #2

Specialty 2

What is specialty of doctor #2

Specialty Doctors Address #2

Street Address City State / Province / Region ZIP / Postal Code

Phone #2

Specialty Doctors Name #2 Phone

Fax #2

Specialty Doctors Name #2 Fax

Specialty Doctors Name #3

Specialty 3

What is specialty of doctor #3

Specialty Doctors Address #3

Street Address City State / Province / Region ZIP / Postal Code

Phone #3

Specialty Doctors Name #3 Phone

Fax #3

Specialty Doctors Name #3 Fax

Hospitalizations

Please list previous hospitalization and serious illnesses in the past three years

Hospitalization last three years:

Yes

Date #1

MM slash DD slash YYYY

Date of Hospitalization

Reason #1

Reason for Hospitalization

Date #2

MM slash DD slash YYYY

Date of Hospitalization #2

Reason #2

Reason for Hospitalization #2

Date #3

MM slash DD slash YYYY

Date of Hospitalization #3

Reason #3

Reason for Hospitalization #3

Use of Alcohol, Tobacco, Coffee, and CBC

Please describe frequency and amount:

Use of Alcohol

Yes

Frequency and Amount

Use of Alcohol

Use of Tobacco

Yes

Frequency and Amount

Use of Tobacco

Use of Coffee

Yes

Frequency and Amount

Use of Coffee

Use of CBC

Yes

Frequency and Amount

Use of CBC

Mobility

Please describe any mobility issues you have had in the last three years

Mobility Issues

Yes

Have you had any problems with walking and/ or mobility in the past three years, i.e balance/ability to walk?

Describe Gait and Mobility

i.e. Pace, Stride

Medical Appliances or Assistive Devices?

Yes

Are you currently using any medical appliances or assistive devices?

Type of Appliance or Device:

Cane

Wheelchair

Walker

Electric Scooter

Please check all that apply

Recent Falls / Injuries?

Please describe and recent falls or injuries

Transportation

Please describe all transportation methods

Are You Still Driving?

Yes

Do You Require Transportation Help?

Yes

Do you require transportation to / from appointments / outings

Who Provides Transportation?

Family Member

Caregiver

Para Transit

Uber

Taxi

Other

Medical Diagnosis

Describe Your Health?

Good

Fair

Poor

Do You Have Any Medical Problems?

Physical

Cognitive

Psychiatric

Depression

Anxiety

Please check all that apply

Distribution of Medication?

Out of Original Medicine Bottle?

Weekly / Monthly Medi-Set

What is the System for Distribution of Medication?

Who Administers Medication?

Self

Caregiver

Family Member

Please choose all that apply

Who is Responsible for Prescription?

Self

Caregiver

Family Member

Other

Person responsible for prescription reorder/refills

List Medications

Please complete form or upload a list if available of all Rx & OTC

Upload List of Medications

Max. file size: 50 MB.

List Medications

Medication Name, Strength, Directions, and What Medication Use (Example: Calcium, 500mg, 2 Tablets Daily, Bone Health)

Medication Allergies or Adverse Reactions

Please list all medication to which you’ve had allergic or adverse reactions. (Example: Medication Name, Type of Reaction)

Medical Information

Please answer all the following Yes/No questions

Glaucoma

Yes

Do you have Glaucoma?

Macular Degeneration

Yes

Do you have Macular Degeneration?

Blindness

Yes

Do you have Blindness?

Blurred Vision

Yes

Do you have Blurred Vision?

Cataracts

Yes

Do you have Cataracts?

Seizures - include last date of seizure

Yes

Do you have Seizures?

Date of Seizure

MM slash DD slash YYYY

High Blood Pressure

Yes

Do you have High Blood Pressure?

Low Blood Pressure

Yes

Do you have Low Blood Pressure?

Stroke or Transient Ischemic Attacks

Yes

Do you have Stroke or Transient Ischemic Attacks?

Note any Residuals

Note any residuals from Stroke or transient ischemic attacks

Angina

Yes

Do you have Angina?

Heart Conditions

Yes

Do you have Heart Conditions?

Chest Pain

Yes

Do you have Chest Pain?

If Yes Specify

If Yes Specify Heart Conditions

Circulatory Disorders

Yes

Do you have Circulatory Disorders including Skin Ulcers?

Imbalance

Yes

Including dizziness, unsteadiness, imbalance, weakness or fainting?

Falls or Fractures

Yes

Do you have any Falls or Fractures?

If Yes Date

MM slash DD slash YYYY

Please list the date of your last fall or fracture

Arthritis

Yes

Do you have Arthritis?

Degenerative Joint Disease

Yes

Do you have Degenerative Joint Disease?

Joint Replacement

Yes

Do you have Joint Replacement?

Osteoporosis

Yes

Do you have Osteoporosis?

Compression Fracture

Yes

Do you have Compression Fracture?

Disorder of the Blood

Yes

Do you have Disorder of the Blood?

Disorder of the Immune System

Yes

Do you have Disorder of the Immune System?

Diabetes or Complications of Diabetes

Yes

Do you have Diabetes or Complications of Diabetes?

Type

Type 1

Type 2

Insulin Injections

Type of Diabetes

Any Diabetic Complications

Please explain Diabetes Complications

Cancer

Yes

Do you have Cancer?

Type

Type of Cancer

Memory Issues

Yes

Do you have Cognition, short-term memory loss, confusion, other dementia, forgetfulness?

Diagnoses

What is your diagnosis?

Date

MM slash DD slash YYYY

Date of your diagnosis?

Psychiatric Condition

Yes

Do you have depression, anxiety, or any psychiatric condition?

Diagnoses

What is your diagnosis?

Date

MM slash DD slash YYYY

Date of your diagnosis?

Neurological Conditions

Yes

Do you have arkinson disease, tremors, or other neurological conditions?

Kidney Disease

Yes

Do you have Kidney Disease?

Cirrhosis of Liver or Liver Disease

Yes

Do you have Cirrhosis of Liver or Liver Disease?

Emphysema, COPD, Shortness of Breath or Oxygen Use

Yes

Do you have emphysema, COPD, shortness of breath or oxygen use?

Hearing Disease

Yes

Do you have Hearing Disease? Wear hearing aids?

Hearing Disease

Yes

Do you have Hearing Disease? Wear hearing aids?

Other Medical Condition

Yes

Do you have any other medical condition not previously notes?

Diagnoses

What is your diagnosis?

Date

MM slash DD slash YYYY

Date of your diagnosis?

Meals & Feeding Instructions

Any Diet Restrictions

Lo-Sodium

Diabetic

Third Choice

Other

Please choose all that apply

Food Texture

Regular

Cut-up

Mechanical Soft

Puree

Please choose all that apply

Special Dietary Needs

Please explain special dietary needs

Food Allergies

Please explain food allergies

Food Dislikes

Please explain food dislikes

Supplements

Ensure

Boost

Other

Choose all that apply

Family Information / Social History:

Spouse Name

Spouse Age

Spouse Occupation

Spouse Living

Yes

Adult Child Names

Please provide all your Living Adult Children (Name, Age, and City of Residence)

Activity

Activity Level

Please enter a number from 1 to 10.

How would you rate the activity level on a scale 0-10?

Daily Activities

Describe activities on a typical day

Do You Participate in an Exercise Program?

Yes

Date of Last Activity

MM slash DD slash YYYY

Frequency

1-2 times a week

3-5 times a week

Daily

Work History?

What is/was primary occupation/ work history?

Special friends, groups, community service

What are your interests / hobbies?

Do You Own a Pet

Yes

Type and Name

What breed of pet and pets name

REVIEW OF ACTIVITIES OF DAILY LIVING (ADL)

Bathing

Requires no assistance or supervision

Requires cueing or some assistance in bathing

Requires substantial assistance

Unable to perform any of the activity independently

Wash body/hair in tub, or shower, with or without adaptive equipment. If sponge bathes, gets basin, soap, and wash cloth independently

Dressing

Requires no assistance or supervision

Requires cueing or some assistance in bathing (tying shoes, managing zippers)

Requires substantial assistance

Unable to get clothes or get dressed independently

Gets clothes from closets/ drawers, puts on and takes off clothes, fastens closures, with or without adaptive equipment.

Bladder Control

Controls urination or uses devices (ostomy)

Requires occasional verbal reminders to urinate

Requires frequent verbal reminders to urinate or loses control of functions more then 2x week

Unable to control urination – needs protective or loses control of functions more than 2x wk or less.

Ability to perform bladder functions

Bowel Control

Controls defecation or uses devices (ostomy)

Requires occasional verbal reminders to defecate or loses control of functions 2x week or less

Unable to control defecation – needs protective clothing.

Ability to perform bowel functions

Toileting

Requires no assistance/ supervision

Requires occasional assistance

Requires substantial assistance

Unable to perform toileting independently

Getting to/ from “toilet room, “transferring to/ from toilet, cleansing self, rearranging clothes, with or without adaptive equipment

Walking / Mobility

Requires no assistance/ supervision in walking

Requires occasional assistance

Requires substantial assistance moving independently with assistive devices

Unable to walk or move from one place to another/ remains in bed all day.

Ability to walk and move from one place to another inside or outside

Transfers

Requires no assistance / supervision

Requires occasional assistance

Requires substantial assistance

Unable to get out of chair or bed

Ability to move in and out of chair or bed with or without assistive equipment

Eating

Requires no assistance / supervision

Requires some assistance encouragement to eat. (Cutting food, pouring liquids) or feeding.)

Requires substantial assistance to eat or requires presence of another person because of gagging, difficulty swallowing, etc.

Unable to feed self; requires intravenous or tube

Ability to get food or nourishment into the body after it has been prepared and made available

In Home Caregiver

Home Care Agency

Private

Both

None

Home Health Agency

Physical

Occupational

Speech Therapist

None

Review of Instrumental Activities of Daily Living (IADL)

Ability to use telephone

Operates telephone totally independently, looks up numbers, dials numbers

Answers the telephone independently, but needs assistance dialing numbers

Unable to use telephone at all

Shopping

Takes care of all shopping needs independently

Can shop for small purchases and/ or is accompanied when shopping

Completely unable to shop

Food Preparation

Plans, prepares and serves adequate meals independently

Heats and serves prepared meals or prepares some meals

Needs to have all meals prepared and served

Housekeeping

Maintains house alone or with occasional assistance for “heavy” chores

Performs light daily housekeeping tasks

Needs help with all housekeeping and home maintenance tasks

Laundry

Does personal laundry completely

Launders small items- rinses socks, stocking, etc.

All laundry must be done by others

Responsibility for own medications

Takes own medications in correct dosage at correct times

Takes responsibility if medication is prepared in advance in separate dosages

Is not capable of dispensing own medications

Ability to Handle Finance

Manages all financial matters independently (budgets, writes checks, goes to bank)

Manages day-to-day purchase, but needs help with banking, major purchases, etc.

Incapable of handling money

Review of Behavioral Management

Exhibits Appropriate Behavior

Yes

Occasionally requires monitoring and supervision

Yes

Occasionally exhibits behavior that requires monitoring and supervision

Requires monitoring and supervision

Yes

Frequently exhibits behavior that requires monitoring and supervision

Dangerous to self or others and requires intervention

Yes

Exhibits behavior monitored and supervised by caregiver / family member which is often disruptive or dangerous to self or others and requires intervention

What are the most current Challenges

What are the most current Goals

Name of individual completing questionnaire

First Last

Relation

Date

MM slash DD slash YYYY

Thank you for completing this information to the best of your knowledge.

This questionnaire will help expedite and begin the process of creating a care plan that will benefit all parties and will help promote the best quality of life. Kathy C. Faenzi, MA Clinical Gerontologist - Please Click Submit Button Below