SUA Resource Library: 

State Care Recipient Assessments 
Foreword 

In 2012, the Administration for Community Living (ACL), an operating division of the US 

Department of Health and Human Services, began a comprehensive evaluation of its National 

Family Caregiver Support Program (NFCSP). This was the first comprehensive federal evaluation 

of the NFCSP, which serves over 800,000 family caregivers annually. The NFCSP evaluation has 

three broad goals to benefit policy and program decision-making: 

1. Collect and analyze information on program processes and site operations; 

2. Evaluate program efficiency and cost issues for approaches best suited to specific 

contexts; and

3. Evaluate effectiveness of the program’s contribution to family caregivers in terms of 

maintaining their health and well-being, improving their caregiving skills, and 

avoiding or delaying institutional care of the care recipient.

As part of the evaluation survey, State Units on Aging (SUAs) were asked to submit relevant 

documents if they answered ‘yes’ to any of the following five questions: 

 Do you have a statewide task force, commission or coalition specifically to examine 

family caregiver issues?

 Have community needs assessments for caregiver support services been conducted?

 Does your state have a standardized caregiver assessment?

 Does your SUA conduct routine programmatic monitoring of the NFCSP program?

 Do you use a uniform caregiver satisfaction survey across all AAAs?

ACL received assessment tools and grouped them into the following categories:

1. Community Assessment Materials

2. General Customer Satisfaction Survey Materials

3. Grandparent Assessment Materials

4. High-Level Administrative Materials

5. Program Monitoring Materials

6. State Caregiver Assessments

7. State Care Recipient Assessments

8. Task Force Materials

9. Uniform Satisfaction Materials

10. Other Materials

While ACL does not specifically endorse these tools, we are sharing them because they may be 

helpful to other programs. For more information on the NFCSP please go to: 

http://www.aoa.acl.gov/. For more information on the evaluation of the NFCSP please go to: 

http://www.aoa.acl.gov/Program_Results/Program_Evaluation.aspx
State Care Recipient Assessments 

Colorado Consumer Assessment .................................................................................................................. 3 

Delaware Care Recipient Assessment ........................................................................................................... 5 

District of Columbia Care Recipient Detailed Assessment ........................................................................... 6 

Florida Assessment Instructions and Attachments .................................................................................... 51

Kansas Uniform Assessment Instrument .................................................................................................. 140 

South Carolina Client Aging Assessment .................................................................................................. 152 

Tennessee Client Assessment ................................................................................................................... 171 

2
2015 Consumer Assessment Updated February 6, 2015 

I.A. Consumer Demographics

Last Name, First Name, Middle Initial:

Gender:  Male  Female Birth Date: / / Age:

Soc. Sec. Number (last 4 digits): XXX - XX - _ _ _ _ Are you Hispanic or Latino? □ Yes □ No What is your race?

What is your monthly income 

range? 

 

 $ 981 or less 

 $ 982 to $1,226

 $1,227 to $1,815

 $1,816 or more

What is you and your spouse’s 

monthly married income range? 

 

 $1,328 or less 

 $1,329 to $1,660

 $1,661 to $2,457

 $2,458 or more

Marital Status:  Married  Single  Divorced  Widowed  Other

Employment:  Full-time  Part time  Temporary jobs  Not employed

Are you willing to volunteer?  Yes  No  Currently volunteering  Don't know 

Are you a veteran?  Yes  No What is your primary language?

Do you have vision problems?  Yes  No Do you wear eye glasses?  Yes  No

Do you have hearing problems?  Yes  No Do you use a hearing aid?  Yes  No

I. B. Address

Residential Street Address

Residential City or Town State, Residential Zip Code

County of Residence Telephone Number (including area code):

Mailing Address - Street/P.O. Box

Mailing City or Town State, Mailing Zip Code

I.C. Living Situation Information

What is your living arrangement?  Live Alone  Live with spouse/partner  Live with extended family  Live with non-relatives

Where do you live?  Own home  Rent home/apartment/room  Family member's residence  Long-term care facility

 Homeless  Other

What is the name of your spouse (optional if applicable)?

I.D. Consumer Contacts

Name of friend or relative (other than spouse/partner) to contact in case of an emergency:

Relationship to emergency contact (other than spouse/partner):

Telephone number (including area code) of friend or relative to contact in case of an emergency:

Name of your primary care physician:

Telephone number (including area code) of your primary care physician:

I have been informed of the policies regarding voluntary contributions, complaint procedures and appeal rights. 

Signature__________________________________________________________ Date___________________

Colorado Consumer Assessment 3
II.A. Nutrition Checklist (If answer “yes,” circle the score. Add the scores to determine your total nutritional score.) Yes No Yes Score

I have an illness or condition that made me change the kind and/or amount of food I eat. 2

I eat fewer than 2 meals per day. 3

I eat few fruits or vegetables or milk products. 2

I have 3 or more drinks of beer, liquor, or wine almost every day. 2

I have tooth or mouth problems that make it hard for me to eat. 2

I don’t always have enough money to buy the food I need. 4

I eat alone most of the time. 1

I take 3 or more different prescribed or over the counter drugs a day. 1

Without wanting to, I have lost or gained 10 pounds in the last 6 months. 2

I am not always physically able to shop, cook and/or feed myself. 2

What is the consumer's nutritional risk score? 

(0-2 = No Risk 3-5 = Moderate Risk 6 or more = High Risk) Total ‘Yes’ Score: _______

III.A. ADLs (Activities of Daily Living) Yes No III.B. IADLs (Instrumental Activities of Daily Living) Yes No

I can eat without help. I can manage money without help.

I can dress myself without help. I can take care of shopping without help.

I can bathe myself without help. I can take my medication without help.

I can use the toilet without help. I can prepare meals without help.

I can get in and out of bed/chairs without help. I can do ordinary housework without help.

I can get around inside my home without help. I can use the telephone without help.

I can use transportation without help.

Are you currently receiving assistance with ADLs or IADLs from 

anyone?

From whom are you receiving assistance 

with ADLs and or IADLs?

What is the consumer's ADL count? Total ‘No’ Score: _____ What is the consumer's IADL count? Total ‘No’ Score: _____ 

III.C. Other Eligibility Criteria - For assessor’s use only Yes No

Does the consumer require Home Health Aide based on orders from a physician?

Does the consumer reside in a rural area (to justify home delivered meals)?

Can the consumer perform chore activities without help?

Is the consumer homebound? 

Is the consumer homebound because he/she lives in a remote geographic location?

Reason consumer is homebound (other than graphic location):

Comment on the consumer's inability to perform chore services:

Describe how to get to the consumer's home:

Consumer's current level of cognitive functioning:  Alert/oriented  Requires assistance in routine situations due to lack of cognitive functioning

Colorado Consumer Assessment 4
Delaware Care Recipient Assessment 5
NAT 1-9-15

1. INTRODUCTION

1.A. INDIVIDUAL'S IDENTIFICATION

1. Date of the face to face interview for Needs 

Assessment Tool (NAT)

______/______/____________

2. Individual's Last Name

3. Individual's First Name

4. Individual's Middle Initial

5. Individual's Name Suffix (If applicable)

6. Individual's Nickname/ Alias

7. Individual's Date of Birth (DOB)

______/______/____________

8. Individual's Gender

Female

Male

9. Individual's Ethnicity (Check only one.)

Hispanic or Latino

Not Hispanic or Latino

Unknown

10. Individual's Race

American Indian/ Native Alaskan

Asian

Black/ African American

Native Hawaiian/ Other Pacific Islander

Non-Minority (White, non-Hispanic)

White-Hispanic

Unknown/ Unavailable

Other-Document Details in Notes

11. Individual's Social Security Number (SSN)

_________-_________-____________

12a.Does the individual have a Medicaid number?

No

Yes

Pending

12b.Indicate Medicaid recipient number

13a.Does the individual have Medicare?

No

Yes

13b.Indicate Medicare recipient number

14a.Does the individual have any other insurance?

No

Yes

Don't know

14b.Indicate other health insurance information

1.B. ASSESSMENT INFORMATION

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1. PSA number conducting assessment:

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

2. Indicate type of Needs Assessment Tool (NAT)

Annual Care Plan

DC-Domiciliary Care Annual

Initial

Significant Change in Needs

Other-Document Details in Notes

3. Where was the individual interviewed?

AL-Assisted Living

DC-Domiciliary Care

Home

Home of Relative/ Caregiver

Hospital

PCH-Personal Care Home

Other-Document Details in Notes

4. Did the individual participate in the assessment?

No-Must complete 1.B.5

Yes

5. If anyone else participated during the time of the 

needs assessment, please document the name and 

relationship in Notes.

1 - Spouse/ Domestic Partner

2 - Family-Other than Spouse

3 - Legal Guardian

4 - Durable Power of Attorney (POA)

5 - Friend

6 - Other-Document Name and Relationship in Notes

1.C. POWER OF ATTORNEY (POA) / LEGAL GUARDIANSHIP

1a. Does the individual have a legal guardian?

No-Skip to 1.C.2a

Yes

1b. Was proof of legal guardianship provided?

No

Yes

1c. Name of legal guardian

1d. Complete address of legal guardian

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1e. Primary phone number of legal guardian

1f. Secondary phone number of legal guardian

1g. E-mail address of legal guardian

2a. Does the individual have a Power of Attorney (POA)?

No-Skip to 1.D.1a

Yes

2b. Proof of POA provided?

No

Yes

2c. Type of POA

Durable

Financial

Health

Other-Document Details in Notes

2d. Name of POA

2e. Complete address of POA

2f. Primary phone number of POA

2g. Secondary phone number of POA

2h. E-mail address of POA

1.D. INDIVIDUAL'S DEMOGRAPHICS

1a. Is the individual homeless?

No-Skip to 1.D.2

Yes

1b. Does the individual have a place to stay tonight?

No-Document Details in Notes

Yes

1c. Does the individual have a place to stay long-term?

No-Document Details in Notes

Yes

1d. Explain homeless situation:

Cannot afford housing

Evicted

Housing not available

Voluntary

Other-Document Details in Notes

2. Type of PERMANENT residence in which the 

individual resides

AL-Assisted Living

Apartment

DC-Domiciliary Care

Group Home

Nursing Home

Own Home

PCH-Personal Care Home

Relative's Home

Specialized Rehab/ Rehab Facility

State Institution

Other-Document Details in Notes

3. What is the individual's PERMANENT living 

arrangement? (Include in the "Lives Alone" category 

individuals who live in an AL, DC or PCH, pay rent and 

have NO ROOMMATE.)

Lives Alone

Lives with Spouse Only

Lives with Child(ren) but not Spouse

Lives with other Family Member(s)

Unknown

Other-Document Details in Notes

4. Individual's marital status

Single

Married

Divorced

Legally Separated

Widowed

Other-Document Details in Notes

5a. Is the individual a Veteran?

No

Yes

Unable to Determine

5b. Is the individual the spouse/ widow or dependent 

child of a Veteran?

No

Yes

Unable to Determine

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5c. Is the individual receiving Veteran's benefits?

No

Yes

Unable to Determine

6a. Does the individual require communication 

assistance?

No-Skip to 1.D.7a

Yes

Unable to Determine

6b. What type of communication assistance is required?

Assistive Technology

Interpreter

Large Print

Picture Book

Unable to Communicate

Unknown

Other-Document Details in Notes

7a. Does the individual use sign language as their 

PRIMARY language?

No-Skip to 1.D.8

Yes

7b. What type of sign language is used?

American Sign Language

International Sign Language

Makaton

Manually Coded Language-English

Manually Coded Language-Non-English

Tactile Signing

Other-Document Details in Notes

8. What is the individual's PRIMARY language?

English

Russian

Spanish

Other-Document Details in Notes

1.E. INDIVIDUAL'S PERMANENT RESIDENTIAL ADDRESS 

INFORMATION - MUNICIPALITY IS REQUIRED

1. Is the individual's postal/ mailing address exactly the 

same as the residential address?

No-Complete Section 1.E & F

Yes

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2a. Residential County

Adams

Allegheny

Armstrong

Beaver

Bedford

Berks

Blair

Bradford

Bucks

Butler

Cambria

Cameron

Carbon

Centre

Chester

Clarion

Clearfield

Clinton

Columbia

Crawford

Cumberland

Dauphin

Delaware

Elk

Erie

Fayette

Forest

Franklin

Fulton

Greene

Huntingdon

Indiana

Jefferson

Juniata

Lackawanna

Lancaster

Lawrence

Lebanon

Lehigh

Luzerne

Lycoming

McKean

Mercer

Mifflin

Monroe

Montgomery

Montour

Northampton

Northumberland

Perry

Philadelphia

Pike

Potter

Schuylkill

Snyder

Somerset

Sullivan

Susquehanna

Tioga

Union

Venango

Warren

Washington

Wayne

Westmoreland

Wyoming

York

Out of State

2b. Residential Street Address

2c. Residential Address Second Line (Apt or Room #, 

Building or Complex Name, etc.)

2d. Residential Municipality - REQUIRED (usually a 

Township or Boro where individual votes, pays taxes)

2e. Residential City/ Town

2f. Residential State

2g. Residential Zip Code

3. Directions to the individual's home

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4. Does individual reside in a rural area?

No

Yes

5a. Primary Phone Number

5b. Mobile Phone Number

5c. Other Phone Number (Enter number where individual 

can be reached.)

5d. E-mail Address

6. What was the outcome when the individual was 

offered a voter registration form? REQUIRED

AAA will submit completed voter registration

Does not meet voter requirements (i.e. citizenship, etc.).

Individual declined application

Individual declined-already registered

Individual will submit completed voter registration

No Response

1.F. INDIVIDUAL'S POSTAL/MAILING ADDRESS 

INFORMATION

1a. Postal Street Address

1b. Postal Address Line 2 (optional)

1c. Postal City/ Town

1d. Postal State

1e. Postal Zip Code

1.G. EMERGENCY CONTACT

1. Name of Emergency Contact

2. Relationship of Emergency Contact

3. Telephone Number of Emergency Contact

4. Work Telephone Number of Emergency Contact

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2. USE OF MEDICAL SERVICES

2.A. HOSPITAL, NURSING FACILITY, ER, INPATIENT 

PSYCHIATRIC VISITS/STAYS

1. Has the individual stayed in the HOSPITAL in the 

LAST 12 MONTHS?

No-Skip to 2.A.3

Yes-Complete 2.A.2

Unable to Determine-Document Details in Notes

2. The approximate number of times the individual has 

stayed overnight in the HOSPITAL in the LAST 12 

MONTHS. Document Details in Notes

3. The approximate number of times the individual has 

visited the ER in the LAST 12 MONTHS and was NOT 

admitted.

4. The approximate number of times the individual was 

admitted to a NURSING FACILITY in the LAST 12 

MONTHS. Document Details in Notes

5. The approximate number of times the individual was 

an inpatient in a PSYCHIATRIC Facility in the LAST 24 

MONTHS. Document Details in Notes

6. The number of times the individual has had 

outpatient surgery in the LAST 12 MONTHS:

0

1

2

3

4

Other-Document Details in Notes

2.B. PRIMARY PHYSICIAN INFORMATION

1. Does the individual have a PRIMARY care physician?

No

Yes

2. PRIMARY Physician's Name

3. PRIMARY Physician's Street Address

4. PRIMARY Physician's City or Town

5. PRIMARY Physician's State

6. PRIMARY Physician's Zip Code

7. PRIMARY Physician's Business Phone Number 

(Requires 10 digits to transfer to SAMS, optional 1-5 digit 

extension.)

8. PRIMARY Physician's FAX Number

9. PRIMARY Physician's E-MAIL ADDRESS

10. Additional Physicians

11. Does the individual receive alternative medical care 

from a practitioner?

No-Skip to 3.A.1

Yes-Complete 2.B.12

12. Select the type of alternative medical care-Document 

Details in Notes

Acupuncturist

Chiropractor

Herbalist

Homoeopathist

Masseur

Other-Document Details in Notes

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3. SAINT LOUIS UNIVERSITY MENTAL STATUS (SLUMS)

3.A. SLUMS PREPARATION

1. Determine if the individual is alert. Alert indicates 

that the individual is fully awake and able to focus.

Alert

Confused

Distractible

Drowsy

Inattentive

Preoccupied

2. Do you have trouble with your memory?

No

Yes

3. SLUMS is being completed as which of the following?

SLUMS is a new screening

SLUMS is a copy from the LCD

4. May I ask you some questions about your memory?

No

Yes

Other-Document Details in Notes

5. Is the individual able to complete the SLUMS Exam?

No-Document Details in Notes & Skip to 3.D.1a

Yes

3.B. SLUMS QUESTIONNAIRE (Each score is beside the 

response.)

1. What DAY of the week is it?

1 - Correct (1)

2 - Incorrect (0)

2. What is the YEAR?

1 - Correct (1)

2 - Incorrect (0)

3. What is the name of the STATE we are in?

1 - Correct (1)

2 - Incorrect (0)

4. Please remember these five objects. I will ask you 

what they are later. Apple, Pen, Tie, House, Car

5a. You have $100 and you go to the store and buy a 

dozen apples for $3 and a tricycle for $20. How much did 

you spend?

1 - Correct ($23) (1)

2 - Incorrect (0)

3 - Unanswered (0)

5b. How much do you have left?

1 - Correct ($77) (2)

2 - Incorrect (0)

3 - Unanswered (0)

6. Please name as many animals as you can in one 

minute.

0-4 (0)

5-9 (1)

10-14 (2)

15+ (3)

Unanswered (0)

7. What were the five objects I asked you to 

remember? (1 point for each one correct.)

Apple (1);

Pen (1);

Tie (1);

House (1);

Car (1);

Unanswered/ None Correct (0)

8. I am going to give you a series of numbers and I 

would like you to give them to me backwards. For 

example, if I say four-two, you would say two-four.

8-7 (78) (0);

6-4-9 (946) (1);

8-5-3-7 (7358) (1);

Unanswered/ None correct (0)

9. This is a clock face. Please put in the hour markers 

and the time at ten minutes to eleven o'clock.

Hour markers correct (2);

Time correct (2);

Unanswered/ None Correct (0)

10a.Place an X in the triangle

1 - Correct (Triangle) (1)

2 - Incorrect (0)

10b.Which of the figures is the largest?

1 - Correct (Square) (1)

2 - Incorrect (0)

11. I am going to tell you a story. Please listen carefully 

because afterwards, I’m going to ask you some questions 

about it.

What was the female's name? (Jill) (2);

What state did she live in? (Illinois) (2);

What work did she do? (Stockbroker) (2);

When did she go back to work? (Kids were teenagers) 

(2)

Unanswered/ None Correct (0)

3.C. SLUMS RESULTS

1. SLUMS Consumers Total Score

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2. Record the highest grade (1-12) the individual 

completed in school.

3. Identify the highest educational degree that the 

individual obtained.

High School Graduate/ or GED

Associate's Degree

Bachelor's Degree

Graduate's Degree

Doctoral's Degree

Other-Document Details in Notes

4. Care Manager's conclusion after completion of the 

individual's SLUMS Exam:

Normal (HS 27+, Non HS 25+)

MNCD-Mild Neurocognitive Disorder (HS 21-26, Non HS 

20-24)

Mild Dementia (HS 16-20, Non HS 15-19)

Moderate Dementia (HS 11-15, Non HS 11-14)

Severe Dementia (Any 10 or Less)

3.D. COGNITIVE FUNCTION

1a. Does the individual exhibit any cognitive 

impairments?

No-Skip to 4.A.1

Yes-Complete 3.D

1b. Does this impairment interfere with the individual's 

ability to function daily?

No-Skip to 4.A.1

Yes-Document Details in Notes

1c. Is the individual able to direct/ supervise his own 

care with the impairment?

No-Complete 3.D.1d

Yes

1d. Does the individual have a representative who is able 

and willing to direct the individual's care because of the 

impairment?

No

Yes-Complete 3.D.1e

1e. Document contact information (Name, Relationship, 

Phone Number, etc.) of the individual who is willing to 

supervise care. Additional space in Notes

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4. DIAGNOSES

4.A. RESPIRATORY

1. Select all RESPIRATORY diagnoses:

None-Skip to 4.B.1

Asthma

COPD-Chronic Obstructive Pulmonary Disease

Emphysema

Pulmonary Edema

Respiratory Failure

Other-Document Details in Notes

2. Signs and symptoms of RESPIRATORY diagnoses:

None

Chest Tightness

Cough

Frequent Respiratory Infections

Respiratory Failure

Shortness of Breath

Wheezing

Other-Document Details in Notes

3. Current treatments for RESPIRATORY diagnoses:

None

Medications-List in 9.D

Oxygen

Respiratory Treatments (Nebulizers, Inhalants, etc.)

Suctioning

Tracheostomy/ Trach Care

Ventilator/ Vent Care

Other-Document Details in Notes

4. Do the RESPIRATORY diagnoses affect the 

individual's ability to function?

No

Yes-Document Details in Notes

5. Who manages care of the RESPIRATORY 

condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

6. Does the individual need additional assistance in 

managing the care of the RESPIRATORY condition(s)?

No

Yes-Document Details in Notes

4.B. HEART/ CIRCULATORY SYSTEMS

1. Select all HEART/ CIRCULATORY systems diagnoses:

None-Skip to 4.C.1

A-Fib and other Dysrhythmia, Bradycardia, Tachycardia

Anemia

Ascites

CAD-Coronary Artery Disease: including Angina, 

Myocardial Infarction, ASHD

DVT-Deep Vein Thrombosis

Heart Failure: including CHF, Pulmonary Edema

Hypertension

PE-Pulmonary Embolus

PVD/PAD (Peripheral Vascular or Artery Disease)

Other-Document Details in Notes

2. Signs and symptoms of the HEART/ CIRCULATORY 

systems diagnoses:

None

Activity Intolerance

Chest Pains

Edema in Extremities

Fainting (Syncope)

Palpitations

Shortness of Breath

Skin Discoloration

Weakness

Other-Document Details in Notes

3. Current treatments for HEART/ CIRCULATORY 

systems diagnoses:

None

Cardiac Rehabilitation

Compression Device, TED Hose, Ace Bandage Wrap(s)

Medications-List in 9.D

Pacemaker

Special Diet

Other-Document Details in Notes

4. Do the HEART/ CIRCULATORY systems diagnoses 

affect the individual's ability to function?

No

Yes-Document Details in Notes

5. Who manages care of the HEART/ CIRCULATORY 

systems condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

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6. Does the individual need additional assistance in 

managing the care of the HEART/ CIRCULATORY systems 

condition(s)?

No

Yes-Document Details in Notes

4.C. GASTROINTESTINAL

1. Select all GASTROINTESTINAL diagnoses:

None-Skip to 4.D.1

Barrett's Esophagus

Crohn's Disease

Diverticulitis

GERD

Hernia

IBS-Irritable Bowel Syndrome

Laryngeal Reflux Disease

Other-Document Details in Notes

2. Signs and symptoms of GASTROINTESTIONAL 

diagnoses:

None

Abdominal Pain

Bloated

Constipation

Diarrhea

Flatulence

Heartburn

Rectal Bleeding

Other-Document Details in Notes

3. Current treatments for GASTROINTESTINAL 

diagnoses:

None

Aspiration Precautions

Feeding Tube-Document Type in Notes

Medications-List in 9.D

Ostomy-Document Type in Notes

Speech Therapy

TPN-Total Parenteral Nutrition

Other-Document Details in Notes

4. Do the GASTROINTESTINAL diagnoses affect the 

individual's ability to function?

No

Yes-Document Details in Notes

5. Who manages care of the GASTROINTESTINAL 

condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

6. Does the individual need additional assistance in 

managing the care of the GASTROINTESTINAL 

condition(s)?

No

Yes-Document Details in Notes

4.D. MUSCULOSKELETAL

1. MUSCULOSKELETAL diagnoses and/ or signs and 

symptoms of MUSCULOSKELETAL diagnoses:

None-Skip to 4.E.1

Ambulatory Dysfunction

Amputation-Document Details in Notes

Arthritis-Document Type of Arthritis in Notes

Contracture(s)

Fractures-Document Details in Notes

Joint Deformity

Limited Range of Motion

Muscular Dystrophy

Osteoporosis

Paraplegia

Poor Balance

Quadriplegia

Spinal Stenosis

Spasms

Weakness

Other-Document Details in Notes

2. Current treatments for MUSCULOSKELETAL 

diagnoses::

None

Assistive Devices-Document Details in Notes

Brace(s)

Cast

Elevate Legs

Medication(s)-List in 9.D

Physical/ Occupational therapy

Prosthesis(es)

Splint

Traction

Other-Document Details in Notes

3. Do the MUSCULOSKELETAL diagnoses affect the 

individual's ability to function?

No

Yes-Document Details in Notes

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4. Who manages care of the MUSCULOSKELETAL 

condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

5. Does the individual need additional assistance in 

managing the care of the MUSCULOSKELETAL 

condition(s)?

No

Yes-Document Details in Notes

4.E. SKIN

1. Select all SKIN diagnoses:

None-Skip to 4.F.1

Dry Skin

Incision (surgical)

Psoriasis

Rash

Ulcer

Wound

Other-Document Details in Notes

2. Check ALL affected SKIN location(s):

Abdomen

Ankle(s)

Arm(s)

Back of Knee(s)

Buttock(s)

Chest

Face

Foot/ Feet

Hip(s)

Leg(s)

Lower Back

Shoulder Blade(s)

Spine

Tailbone

Other-Document Details in Notes

3. Identify the highest known ULCER STAGE.

0 - Unstageable

1 - Stage 1 - Redness

2 - Stage 2 - Partial Skin Loss

3 - Stage 3 - Full Thickness

4 - Stage 4 - Muscle and/or Bone Exposed

5 - Unknown

4. Signs and symptoms of the SKIN diagnoses:

None

Edema/ Swelling

Excoriation

Odor/ Drainage

Pain

Redness/ Discoloration

Skin Tears

Other-Document Details in Notes

5. Current treatments for SKIN diagnoses:

None

Debridement

Medications-List in 9.D

Pressure Relieving Devices

Surgery

Unna Boot(s)

Wound Dressing

Wound Therapy

Wound VAC

Other-Document Details in Notes

6. Do the SKIN diagnoses affect the individual's ability 

to function?

No

Yes-Document Details in Notes

7. Who manages care of the SKIN condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

8. Does the individual need additional assistance in 

managing the care of the SKIN condition(s)?

No

Yes-Document Details in Notes

4.F. ENDOCRINE/ METABOLIC SYSTEMS

1. Select all ENDOCRINE/ METABOLIC systems 

diagnoses:

None-Skip to 4.G.1

Ascites

Cirrhosis

Diabetes Mellitus (DM)-Insulin Dependent

Diabetes Mellitus (DM)-Non-Insulin Dependent

Diabetic Neuropathy

Hypoglycemia

Thyroid Disorder

Other-Document Details in Notes

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2. Signs and symptoms of the ENDOCRINE/ METABOLIC 

systems diagnoses:

None

Agitation

Anxiety

Blurred Vision

Confusion

Frequent Urination

Increased Thirst

Lethargy

Slow Healing Sores

Sweating

Other-Document Details in Notes

3. Current treatments for ENDOCRINE/ METABOLIC 

systems diagnoses:

None

Blood Sugar Monitoring

Blood Transfusions

Medications-List in 9.D

Special Diet

Other-Document Details in Notes

4. Do the ENDOCRINE/ METABOLIC systems diagnoses 

affect the individual's ability to function?

No

Yes-Document Details in Notes

5. Who manages care of the ENDOCRINE/ METABOLIC 

systems condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

6. Does the individual need additional assistance in 

managing the care of the ENDOCRINE/ METABOLIC 

systems condition(s)?

No

Yes-Document Details in Notes

4.G. GENITOURINARY

1. Select all GENITOURINARY diagnoses:

None-Skip to 4.H.1

Ascites

Benign Prostatic Hypertrophy (BPH)

Bladder Disorders, including neurogenic or overactive 

bladder, urinary retention

Frequent Urinary Tract Infections (UTI)

Renal Insufficiency/ Failure (ESRD)

Other-Document Details in Notes

2. Signs and symptoms of the GENITOURINARY 

diagnoses:

None

Abdominal Distention/ Bloated

Bladder Spasms

Frequent Urination

Incontinence

Low/ No Urine Output

Painful/ Burning Urination

Urinary Retention

Other-Document Details in Notes

3. Current treatments for GENITOURINARY diagnoses:

None

Catheter-Complete 4.G.4

Dialysis

Fluid Restrictions

Medications-List in 9.D

Ostomy

Other-Document Details in Notes

4. If the individual has a catheter, indicate the type.

External/ Condom

Indwelling

Straight Catheterization

Suprapubic

Other-Document Details in Notes

5. Do the GENITOURINARY diagnoses affect the 

individual's ability to function?

No

Yes-Document Details in Notes

6. Who manages care of the GENITOURINARY 

condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

7. Does the individual need additional assistance in 

managing the care of the GENITOURINARY condition(s)?

No

Yes-Document Details in Notes

4.H. GYNECOLOGICAL

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1. Select all GYNECOLOGICAL diagnoses:

None-Skip to 4.I.1

Abnormal Pap

Breast Lumps

Diseases of the Uterus/ Cervix-Document Details in Notes

Prolapsed Uterus

Other-Document Details in Notes

2. Signs and symptoms of GYNECOLOGICAL diagnoses:

None

Bleeding

Bulging

Discharge

Infection(s)

Itching

Odor

Other-Document Details in Notes

3. Current treatments for GYNECOLOGICAL diagnoses:

None

Medications-List in 9.D

Sitz Bath

Other-Document Details in Notes

4. Do the GYNECOLOGICAL diagnoses affect the 

individual's ability to function?

No

Yes-Document Details in Notes

5. Who manages care of the GYNECOLOGICAL 

condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

6. Does the individual need additional assistance in 

managing the care of the GYNECOLOGICAL condition(s)?

No

Yes-Document Details in Notes

4.I. INFECTIONS/ IMMUNE SYSTEMS

1. Select all INFECTION/ IMMUNE system diagnoses:

Abscesses

None-Skip to 4.J.1

AIDS Asymptomatic

AIDS Symptomatic

Hepatitis

HIV

MRSA/ VRE/ C-Dif

Sepsis

TB-Tuberculosis

Other-Document Details in Notes

2. If HIV or AIDS is indicated in 4.I.1, has the individual 

ever had lab results of CD4 count under 400?

No

Yes

Unknown

3. Signs and symptoms of the INFECTION/ IMMUNE 

system conditions. Use Notes for additional text.

4. Current treatments for INFECTION/ IMMUNE system 

diagnoses:

None

Intravenous Therapy

Isolation

Laboratory result monitoring

Medication(s)-List in 9.D

Transfusion(s)

Wound Therapy

Other-Document Details in Notes

5. Do the INFECTIONS/ IMMUNE system diagnoses 

affect the individual's ability to function?

No

Yes-Document Details in Notes

6. Who manages care of the INFECTION/ IMMUNE 

system condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

7. Does the individual need additional assistance in 

managing the care of the INFECTIONS/ IMMUNE system 

condition(s)?

No

Yes-Document Details in Notes

4.J. CANCER

1. Does the individual have any current CANCER 

diagnoses?

No-Skip to 4.K.1

Yes

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2. If Yes, identify the STAGE of CANCER:

0 - Unstageable

1 - Stage 1

2 - Stage 2

3 - Stage 3

4 - Stage 4

5 - Unknown

3. Select all current CANCER diagnoses:

Basal Cell

Bile Duct

Bladder

Bone

Brain

Breast

Cervical

Colon

Colorectal

Endometrial

Esophageal

Gallbladder

Gastric

Hodgkin's Disease

Kidney

Leukemia

Liver

Lung

Lymphatic

Multiple Myeloma

Non-Hodgkin's Lymphoma

Oral

Ovarian

Pancreatic

Prostate

Sarcoma

Skin

Testicular

Throat

Thyroid

Uterine

Vaginal

Other-Document Details in Notes

4. Signs and symptoms of the CANCER diagnoses:

None

Abdominal distention

Anemia

Anorexia

Anxiety

Ascites

Cachexia

Confusion

Constipation

Cough

Diaphoresis

Diarrhea

Disorientation

Dysphagia (choking)

Dyspnea at rest

Dyspnea upon exertion

Edema

Fatigue

Hallucinations

Hematuria

Insomnia

Jaundice

Loss of appetite

Lymphedema

Mental status changes

Nausea

Oral thrush

Pain

Special diet

Terminal/ end stage dx

Vomiting

Weakness

Weight loss

Other-Document Details in Notes

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5. Current treatments for CANCER diagnoses:

None

Aspiration Precautions

Bone Marrow Transplant

Chemo/ Radiation Combination

Chemotherapy

Hospice Care

Indwelling Catheter/ Services

Maintenance/ Preventative Skin Care

Medications-List in 9.D

Occupational Therapy

Ostomy/ Related Services

Oxygen

Palliative Care

Physical Therapy

Radiation

Respiratory Therapy

Restorative Care

Speech Therapy

Suctioning

Surgery

Transfusion(s)

Tube Feedings/ TPN

Other-Document Details in Notes

6. Do the CANCER diagnoses affect the individual's 

ability to function?

No

Yes-Document Details in Notes

7. Who manages care of the CANCER condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Details in Notes

8. Does the individual need additional assistance in 

managing the care of the CANCER condition(s)?

No

Yes-Document Details in Notes

4.K. EARS, NOSE & THROAT (ENT)

1. Select all ENT diagnoses:

None-Skip to 4.L.1

Deafness

Deviated Septum

Rhinitis

Sinusitis

Tinnitus

Other-Document Details in Notes

2. Signs and symptoms of the ENT diagnoses:

None

Choking

Congestion

Difficulty Breathing

Difficulty Swallowing

Dizziness

Fullness/ Pressure in Head/ Sinuses

Headaches

Hearing Loss

Hoarseness

Persistent Cough

Other-Document Details in Notes

3. Current treatments for ENT diagnoses:

None

Esophageal Dilatation

Feeding Tube

Hearing Aid

Implants

Medications-List in 9.D

Tracheostomy

Other-Document Details in Notes

4. Do the ENT diagnoses affect the individual's ability to 

function?

No

Yes-Document Details in Notes

5. Who manages care of the ENT condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other

6. Does the individual need additional assistance in 

managing the care of the ENT condition(s)?

No

Yes-Document Details in Notes

4.L. EYES

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1. What EYE diagnoses/ disorders have been confirmed 

and documented by health/ medical professionals?

None-Skip to 4.M.1

Blindness

Cataracts

Glaucoma

Legally Blind

Macular Degeneration

Partially Sighted/ Low Vision

Retinal Detachment

Other Visual Impairments-Document Details in Notes

2. Signs and symptoms for EYE conditions and/ or 

diagnoses:

None

Double /Blurred Vision

Dry Eye

Itching

Redness

Other-Document Details in Notes

3. Current treatments for EYE conditions and/ or 

diagnoses:

None

Corrective Lenses

Corrective Surgery

Medications-List in 9.D

Other-Document Details in Notes

4. Do the EYE diagnoses affect the individual's ability to 

function?

No

Yes-Document Detail in Notes

5. Who manages care of the EYE condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Detail in Notes

6. Does the individual need additional assistance in 

managing the care of the EYE condition(s)?

No

Yes-Document Details in Notes

4.M. MOUTH

1. Select all MOUTH conditions and/ or diagnoses:

None-Skip to 5.A.1

Dry Mouth

Edentulous/ Toothless

Gingivitis

Thrush

Ulcer(s)

Other-Document Details in Notes

2. Current treatments for MOUTH conditions and/ or 

diagnoses:

None

Dental Hygiene

Medications-List in 9.D

Other-Document Details in Notes

3. Signs and symptoms of MOUTH conditions and/ or 

diagnoses:

None

Halitosis

Pain

Swelling

Thrush

Other-Document Details in Notes

4. Do the MOUTH diagnoses affect the individual's 

ability to function?

No

Yes-Document Detail in Notes

5. Who manages care of the MOUTH condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Detail in Notes

6. Does the individual need additional assistance in 

managing the care of the MOUTH conditions?

No

Yes-Document Details in Notes

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5. NEUROLOGICAL (MANDATORY completion of Section 8 if 

Neurological diagnosis)

5.A. NEUROLOGICAL

1. If there are NEUROLOGICAL diagnoses, select all 

types & completion of Section 8 (Behaviors) is 

MANDATORY.

None-Skip to 6.A.1

ALS

Alzheimer's Disease

Autism

Cerebral Palsy

CVA/ TIA/ Stroke

Dementia (Include all Non-Alzheimer's Dementia)

Multiple Sclerosis

Muscular Dystrophy

Parkinson's Disease

Neuropathy

Seizure Disorder

TBI-Traumatic Brain Injury

Other-Document Details in Notes

2. What characteristics describe the individual's 

COGNITIVE state?

Appears to be cognitively intact

Executive functioning impaired-Document Details in Notes

Inability to adapt to changes in routine or location

Inability to follow commands

Non-communicative

Poor long term memory

Poor short term memory

Slow response to questions

Other-Document Details in Notes

3. Signs and symptoms of NEUROLOGICAL diagnoses:

None

Ambulation Dysfunction

Aphasia

Fatigue

Muscle Spasticity/ Stiffness

Pain

Poor Balance

Rigidity

Shuffling Gait

Spasms

Tremors/ Twitches

Other-Document Details in Notes

4. Current treatments for NEUROLOGICAL diagnoses:

None

No Treatment Available

Braces

Cervical Collar

Cognitive/ Behavioral Therapy

Electrical Stimulation Device

Medications-List in 9.D

Seizure Precautions

Therapy-Document Details in Notes

Traction

Other-Document Details in Notes

5. Do the NEUROLOGICAL diagnoses affect the 

individual's ability to function?

No

Yes-Document Detail in Notes

6. Who manages care of the NEUROLOGICAL 

condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Detail in Notes

7. Does the individual need additional assistance in 

managing the care of the NEUROLOGICAL condition(s)?

No

Yes-Document Details in Notes

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6. INTELLECTUAL/ DEVELOPMENTAL DISABILITY (I/DD) 

(MANDATORY completion of Section 8 if I/DD diagnosis)

6.A. INTELLECTUAL/ DEVELOPMENTAL DISABILITY (I/DD)

1. Does the individual have a diagnosis of Intellectual/ 

Developmental Disability (I/DD) from birth to 22nd 

birthday or known to the ID system?

No-Skip to 7.A.1

Yes-Completion of Section 8 (Behaviors) is MANDATORY.

2. Is the individual able to self-manage care of the I/DD 

condition?

No

Yes

Unable to Determine

3. Does the I/DD diagnosis affect the individual's ability 

to function?

No

Yes

Unable to Determine

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7. MENTAL HEALTH (MANDATORY completion of Section 8 if 

Psychiatric diagnosis)

7.A. PSYCHIATRIC

1. If there are PSYCHIATRIC diagnoses, select all types 

& completion of Section 8 (Behaviors) is MANDATORY.

None-Skip to 7.B.1

Anxiety Disorders

Bipolar Disorders

Depressive Disorders

Disruptive Impulse Control/ Conduct Disorders

Eating Disorders

Obsessive Compulsive Disorders

Personality Disorders

Schizophrenia/ Other Psychotic Disorders

Sleep/ Wake disorders

Somatic Symptom/ Related Disorders

Trauma/ Stress/ Related Disorders

Other-Document Details in Notes

2. Signs and Symptoms of PSYCHIATRIC conditions:

None

Exhibits Other Unusual Behavior-Document Details in 

Notes

Experiences Sleep Disturbances

Experiencing Hallucinations/ Delusions

Fearful/ Suspicious

Feels Depressed, Sad or Hopeless

Feels Lonely

Irritable/ Easily Upset

Physically/ Verbally Abusive

Withdrawn/ Lethargic

Worried/ Anxious

Other-Document Details in Notes

3. Current treatments for PSYCHIATRIC diagnoses:

None

No Treatment Available

ECT-Electroconvulsive Therapy

Medications-List in 9.D

Outpatient Psychiatric Care

Other-Document Details in Notes

4. Do the PSYCHIATRIC diagnoses affect the 

individual's ability to function?

No

Yes-Document Detail in Notes

5. Who manages care of the PSYCHIATRIC 

condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Detail in Notes

6. Does the individual need additional assistance in 

managing the care of the PSYCHIATRIC condition(s)?

No

Yes-Document Details in Notes

7.B. SUICIDE SCREENING

1. Have you thought about hurting yourself or taking 

your life in the PAST 30 DAYS?

No

Yes-Complete Aging Suicide Risk Assessment

Individual Refused to Answer

2. When did you have these thoughts, and do you have 

a plan to take your life?

No

Yes-Document Details in Notes

Individual Refused to Answer

3. Have you ever had a suicide attempt?

No

Yes-Document Details in Notes

Individual Refused to Answer

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District of Columbia Care Recipient Detailed Assessment 25
8. BEHAVIORS - MANDATORY if Neurological, I/DD or 

Psychiatric Diagnosis

8.A. BEHAVIORS

1. Does the individual present with any BEHAVIORAL 

signs/ symptoms? This Section is REQUIRED if any 

Neurologic, IDD or Psychiatric Diagnoses were noted in 

Section 5, 6 or 7.

No-Skip to 8.B.1

Yes-Completion of Section 8-Behaviors is MANDATORY.

Unable to Determine-Completion of Section 8-Behaviors is 

MANDATORY.

2a. Does the individual exhibit PHYSICAL behavioral 

symptoms toward OTHERS?

No-Skip to 8.A.3a

Yes-Complete 8.A.2b-c

2b. Specify ALL types of aggressive PHYSICAL behavior 

toward OTHERS (If not listed, document in Notes.)

Biting

Hair pulling

Hitting

Kicking

Picking

Scratching

Sexual acting out/ behavior

Spitting

Other-Document Details in Notes

2c. Does the aggressive PHYSICAL behavior toward 

OTHERS interfere with the individual's ability to function 

daily?

No-Document in Notes why the behavior does NOT 

interfere.

Yes-Document in Notes how it interferes.

3a. Does the individual exhibit aggressive PHYSICAL 

behavioral symptoms towards SELF?

No-Skip to 8.A.4a

Yes-Complete 8.A.3b-c

3b. Specify ALL types of aggressive PHYSICAL behavior 

towards SELF (If not listed, document in Notes.)

Biting

Hair pulling

Hitting

Kicking

Picking

Scratching

Spitting

Other-Document Details in Notes

3c. Does the aggressive PHYSICAL behavior toward SELF 

interfere with the individual's ability to function daily?

No-Document in Notes why the behavior does NOT 

interfere.

Yes-Document in Notes how it interferes.

4a. Does the individual exhibit aggressive VERBAL 

behavior symptoms toward OTHERS?

No-Skip to 8.A.5a

Yes-Complete 8.A.4b-c

4b. Specify ALL types of aggressive VERBAL behavior 

towards OTHERS (If not listed, document in Notes.)

Cursing

Screaming

Threatening

Other-Document Details in Notes

4c. Does the aggressive VERBAL behavior toward 

OTHERS interfere with the individual's ability to function 

daily?

No-Document in Notes why the behavior does NOT 

interfere.

Yes-Document in Notes how it interferes.

5a. Does the individual exhibit any GENERAL aggressive 

VERBAL behavior symptoms not specifically directed 

toward self or others?

No-Skip to 8.A.6a

Yes-Complete 8.A.5b-c

5b. Select ALL GENERAL aggressive VERBAL behaviors (If 

not listed, document in Notes.)

Disruptive sounds

Yelling out

Other-Document Details in Notes

5c. Does the GENERAL aggressive VERBAL behavior 

interfere with the individual's ability to function daily?

No-Document in Notes why the behavior does NOT 

interfere.

Yes-Document in Notes how it interferes.

6a. Does the individual exhibit any OTHER behavioral 

symptoms?

No-Skip to 8.B.1

Yes-Complete 8.A.6b-c

6b. Specify ALL OTHER types of behaviors reported (If 

not listed, document in Notes.)

Fecal Smearing

Hoarding

Pacing

Public Disrobing

Rummaging

Sundowner's Syndrome

Other-Document Details in Notes

6c. Do the OTHER types of behaviors interfere with the 

individual's ability to function daily?

No-Document in Notes why the behavior does NOT 

interfere.

Yes-Document in Notes how it interferes.

8.B. ADDICTIVE BEHAVIORS

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1. Has anyone ever expressed concern about your use 

of alcohol or drugs?

No- Skip to Section 9.A.1

Yes-Document Details in Notes and Complete Section 8.B

2. Do you find yourself missing work, family events, 

activities that you once participated in due to over use of 

a substance?

No

Yes-Document Details in Notes

3. Is drinking or use of other substances making your 

home life unhappy?

No

Yes-Document Details in Notes

4. Do you find yourself reaching for an alcoholic drink or 

other substance to get you through an event or 

interaction with certain people?

No

Yes-Document Details in Notes

5. Do you drink or use other substances alone? (Do you 

live alone? Feel lonely?)

No

Yes-Document Details in Notes

6. Have you ever felt remorse (regret) after you've 

drank or used other substance?

No

Yes-Document Details in Notes

7. Do you believe that your drinking or use of other 

substances is causing a financial burden or decline?

No

Yes-Document Details in Notes

8. Do you find your ambition (effort to get up and do 

things each day) has declined since drinking or using 

other substances?

No

Yes-Document Details in Notes

9. Do you find yourself replacing meals with either an 

alcoholic drink or another substance?

No

Yes-Document Details in Notes

10. Does drinking or use of other substances cause you 

to have difficulty sleeping?

No

Yes-Document Details in Notes

11. Do you drink to escape (getaway from) worries or 

troubles?

No

Yes-Document Details in Notes

12. Do you find yourself more depressed since drinking 

or using other substances?

No

Yes-Document Details in Notes

13. Are you having memory problems due to drinking or 

use of other substances?

No

Yes-Document Details in Notes

14. Have you spoken to your doctor about drinking or use 

of other substances?

No

Yes-Document Details in Notes

15. Have you ever been treated in a hospital, 

rehabilitation center or by a doctor for drinking or other 

substance use?

No

Yes-Document Details in Notes

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9. OTHER MEDICAL INFORMATION

9.A. INFORMATION

1. Has the individual exhibited ELOPEMENT behavior in 

the LAST 6 MONTHS? If so, indicate the FREQUENCY.

Never

Less than once a month

Once a month

Several times a month

Several times a week

Daily

Other-Document Details in Notes

2. Does the individual require supervision?

No-Skip to 9.A.4

Yes-Complete 9.A

2a. How long can the individual be routinely left alone? 

Document Details in Notes

Indefinitely

Entire day and overnight

Eight (8) hours or more - day or night

Eight (8) hours or more - daytime only

Four (4) hours or more - day or night

Four (4) hours or more - daytime only

Less than four (4) hours

Cannot be left alone

3. Why does the individual require supervision?

Cognitive diagnosis

Environmental issue

General physical condition

Other-Document Details in Notes

4. Can the individual evacuate their home in the event 

of a fire?

No-See Section 17 Emergency Information

Yes

9.B. FRAILTY SCORE

1. Are you tired?

No

Yes

2. Can you walk up a flight of stairs?

No

Yes

3. Can you walk a city block (250-350 feet)?

No

Yes

4. Do you have more than 5 illnesses?

No

Yes

5. Have you lost more than 5% of your weight in the 

last year?

No

Yes

6. Individual shows symptoms of being frail?

9.C. DEPRESSION /LIFE SATISFACTION

1. Are you basically satisfied with your life?

No

Yes

2. Do you often get bored?

No

Yes

3. Do you often feel hopeless?

No

Yes

4. Do you prefer to stay at home, rather than going out 

and doing new things?

No

Yes

5. Do you ever have feelings of worthlessness?

No

Yes

6. Individual shows symptoms of being depressed?

9.D. MEDICATION MANAGEMENT

1. Does the individual take any PRESCRIBED 

Medications?

No-Skip to 9.D.6

Yes

2. Does the individual have a central venous line?

No

Yes-Document Type & Details in Notes

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3. List all PRESCRIBED medications taken by the 

individual:

Name and Dose: Record the name of the medication and dose ordered.

Form: Code the route of administration using the following list:

1 = by mounth (PO) 7 = topical

2 = sub lingual (SL) 8 = inhalation

3 = intramuscular (IM) 9 = enteral tube

4 = intravenous (IV) 10 = other

5 = subcutaneous (SQ) 11 = eye drop

6 = rectal (R) 12 = transdermal

Frequency: Code the number of times per period the med is administered 

using the following list:

PR = (PRN) as necessary OO = every other day

1H = (QH) every hour 1W = (Q week) once each 

week 

2H = (Q2H) every 2 hours 2W = 2 times every week

3H = (Q3H) every 3 hours 3W = 3 times every week

4H = (Q4H) every 4 hours 4W = 4 times each week

6H = (Q6H) every 6 hours 5W = 5 times each week

8H = (Q8H) every eight hours 6W = 6 times each week

1D = (QD or HS) once daily 1M = (Q month) once/mo.

2D = (BID) two times daily 2M = twice every month

 (includes every 12 hours) C = Continuous

3D = (TID) 3 times daily O = Other

4D = (QID) four times daily

5D = 5 times daily 

gtts (Drops) mEq (Milli-equivalent)

Puffs

gm (Gram) mg (Milligram) % 

(Percentage)

Unit type:

Name Dose Form Freq. PRN # Taken Drug Code Comments

4. Does the individual take all medications as 

prescribed?

No-Document Details in Notes

Yes

5. Does the individual know what medication they take 

and why? Document Details in Notes

No

Yes

Unable to Determine

6. List all OVER THE COUNTER (OTC) medications taken 

by the individual:

Name and Dose: Record the name of the medication and dose ordered.

Form: Code the route of administration using the following list:

1 = by mounth (PO) 7 = topical

2 = sub lingual (SL) 8 = inhalation

3 = intramuscular (IM) 9 = enteral tube

4 = intravenous (IV) 10 = other

5 = subcutaneous (SQ) 11 = eye drop

6 = rectal (R) 12 = transdermal

Frequency: Code the number of times per period the med is administered 

using the following list:

PR = (PRN) as necessary OO = every other day

1H = (QH) every hour 1W = (Q week) once each 

week 

2H = (Q2H) every 2 hours 2W = 2 times every week

3H = (Q3H) every 3 hours 3W = 3 times every week

4H = (Q4H) every 4 hours 4W = 4 times each week

6H = (Q6H) every 6 hours 5W = 5 times each week

8H = (Q8H) every eight hours 6W = 6 times each week

1D = (QD or HS) once daily 1M = (Q month) once/mo.

2D = (BID) two times daily 2M = twice every month

 (includes every 12 hours) C = Continuous

3D = (TID) 3 times daily O = Other

4D = (QID) four times daily

5D = 5 times daily 

gtts (Drops) mEq (Milli-equivalent)

Puffs

gm (Gram) mg (Milligram) % 

(Percentage)

Unit type:

Name Dose Form Freq. PRN # Taken Drug Code Comments

7. Does the individual have any allergies or adverse 

reactions to any medication?

No

Yes-Document Details in Notes

8. What is the individual's ability level to manage 

medication?

1 - Independent-Skip to 9.D.11

2 - Limited Assistance

3 - Total Assistance

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en Drug Code Comments

District of Columbia Care Recipient Detailed Assessment 30
9. If Limited Assistance, indicate ALL types needed for 

MEDICATION MANAGEMENT:

Assistance with Self-Injections/ Independent with Oral 

Medications

Coaxing

Medication Dispenser

Set-up/ Prepackaged

Verbal Reminders

Other-Document Details in Notes

10. Who assists the individual with medication 

administration?

Formal Support-Document Details in Notes

Informal Support-Document Details in Notes

Other-Document Details in Notes

11. Does the individual use herbs or other remedies?

No

Yes-Document Details in Notes.

12. Pharmacy Information (Name, Phone, etc.)

9.E. HEIGHT/WEIGHT

1. What is the individual's height?

2. What is the individual's weight?

3. Document the reason(s) for weight gain or loss (See 

13.B.10)

Diet/ Intentional

Fluid Loss

Fluid Retention

Increased Appetite

Poor Appetite

Unable to Determine

Other

4. Is physician aware of the weight change?

No

Yes

5. What is the individual's weight type?

Normal-height/ weight appropriate

Morbidly Obese

Obese

Overweight

Underweight

9.F. PAIN

1. Does the individual report PAIN?

No-Skip to 10.A.1a

Yes

Unable to determine-Skip to 10.A.1a

2. Location(s) of PAIN site(s)

Back

Bone

Chest

Head

Hip

Incision site

Knee

Soft tissue (muscle)

Stomach

Other Joint-Document Details in Notes

Other-Document Details in Notes

3. Indicate the level of PAIN the individual reports 

using a scale from 0-10 (0=no pain, 10=severe pain)

0=No pain

1

2

3

4

5

6

7

8

9

10=Severe pain

4. Indicate the frequency the individual reports the 

PAIN

Less than Daily

Daily-One Episode

Daily-Multiple Episodes

Continuous

Other-Document Details in Notes

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5. Select all the current treatments for PAIN diagnoses:

None

Acupuncture

Chiropractic Care/ Services

Exercises

Heat/ Cold Applications

Massage

Medications-List in 9.D

Pain Management Center

Physical Therapy

Other-Document Details in Notes

6. PAIN Management

No pain treatment

Treated, full relief

Treated, partial relief

Treated, no or minimal relief

7. Does PAIN affect the individual's ability to function?

No

Yes-Document Detail in Notes

8. Who manages care of the PAIN condition(s)?

Formal Support

Informal Support

Primary Care Physician

Self

Specialty Physician

Other-Document Detail in Notes

9. Does the Individual need additional assistance in 

managing PAIN?

No

Yes-Document Details in Notes

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10. ACTIVITIES OF DAILY LIVING (ADLs)

10.A. ADLs

1a. BATHING: Ability to prepare a bath and wash 

oneself, including turning on the water, regulating 

temperature, etc.

1 - Independent-Skip to 10.A.2a

2 - Limited Assistance

3 - Total Assistance

1b. If Limited Assistance, indicate ALL types needed for 

BATHING:

Assistance with the use of equipment/ assistive devices

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document Details in Notes

1c. BATHING: Assistance currently provided by what 

INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

1d. BATHING: Assistance currently provided by what 

FORMAL supports? Document Details in Notes

None

Aging Programs

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

1e. How often is BATHING support available? Document 

Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

1f. Type of BATHING? Document Details in Notes

Partial

Shower

Sponge bath

Tub

Other-Document Details in Notes

1g. Assistive devices/ adaptive equipment used for 

BATHING? Document Details in Notes

None

Bathtub bench

Grab bar/ tub rail

Handheld shower

Hydraulic lift

Shower bench

Transfer bench

Other

1h. Does the individual need additional assistance in 

BATHING?

No

Yes-Document Details in Notes

2a. DRESSING: Ability to remove clothes from a closet/ 

drawer; application of clothing, including shoes/ socks 

(regular/ TEDS); orthotics; prostheses; removal/ storage 

of items; managing fasteners; and to use any needed 

assistive devices.

1 - Independent-Skip to 10.A.3a

2 - Limited Assistance

3 - Total Assistance

2b. If Limited Assistance, indicate ALL types needed for 

DRESSING:

Assistance with the use of equipment/ assistive device

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document Details in Notes

2c. DRESSING: Assistance currently provided by what 

INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

2d. DRESSING: Assistance currently provided by what 

FORMAL supports? Document Details in Notes

None

Aging Programs

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

2e. How often is DRESSING support available? 

Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

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2f. Assistive devices/ adaptive equipment used for 

DRESSING? Document Details in Notes

None

Buttonhole helper

Shoe horn

Sock cup

Other-Document Details in Notes

2g. Does the individual need additional assistance in 

managing DRESSING?

No

Yes-Document Details in Notes

3a. GROOMING/ PERSONAL HYGIENE: Ability to comb/ 

brush hair; brush teeth; care for/ inset dentures; shave; 

apply make-up (if worn); apply deodorant, etc.

1 - Independent-Skip to 10.A.4a

2 - Limited Assistance

3 - Total Assistance

3b. If Limited Assistance, indicate ALL types needed for 

GROOMING/ PERSONAL HYGIENE:

Assistance with the use of equipment/ assistive devices

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document Details in Notes

3c. GROOMING/ PERSONAL HYGIENE: Assistance 

currently provided by what INFORMAL supports? 

Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

3d. GROOMING/ PERSONAL HYGIENE: Assistance 

currently provided by what FORMAL supports?

None

Aging Programs

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

3e. How often is GROOMING/ PERSONAL HYGIENE 

support available? Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

3f. Are assistive devices/ adaptive equipment used for 

GROOMING/ PERSONAL HYGIENE? Document Details in 

Notes

No

Yes

3g. Does the individual need additional assistance in 

GROOMING/ PERSONAL HYGIENE?

No

Yes-Document Details in Notes

4a. EATING: Ability to eat/ drink; cut, chew, swallow 

food; and to use any needed assistive devices

1 - Independent-Skip to 10.A.5a

2 - Limited Assistance

3 - Total Assistance

4 - Does not eat-Skip to 10.A.4c

4b. If Limited Assistance, indicate ALL types needed for 

EATING:

Assistance with the use of equipment/ assistive devices

Encouragement, cueing or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document in Notes

4c. If response to 10.A.4a is "4-Does not eat", indicate 

type of nutritional intake. Check ALL that apply:

IV Fluids

NPO (nothing by mouth)

Parenteral Nutrition

Tube Feeding

Other-Document Details in Notes

4d. EATING: Assistance currently provided by what 

INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

4e. EATING: Assistance currently provided by what 

FORMAL supports?

None

Aging Programs

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

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4f. How often is EATING support available? Document 

Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

4g. Assistive devices/ adaptive equipment used for 

EATING? Document Details in Notes

Adaptive cup

Adaptive plate

Adaptive utensils

Dentures

Hand split/ braces

Infusion pump

Special utensil/ plate

Other-Document Details in Notes

4h. Does the individual need additional assistance in 

managing EATING?

No

Yes-Document Details in Notes

5a. TRANSFER: Ability to move between surfaces, 

including to/ from bed, chair, wheelchair, or to a standing 

position; onto or off a commode; and to manage/ use any 

needed assistive devices.

1 - Independent-Skip to 10.A.6a

2 - Limited Assistance

3 - Total Assistance

5b. If Limited Assistance, indicate ALL types needed for 

TRANSFER:

Assistance with the use of equipment/ assistive devices

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document Details in Notes

5c. TRANSFER: Assistance currently provided by what 

INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

5d. TRANSFER: Assistance currently provided by what 

FORMAL supports?

None

Aging Programs

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

5e. How often is support available for TRANSFER? 

Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

5f. Assistive devices/ adaptive equipment used for 

TRANSFER? Document Details in Notes

None

Bed rails

Bedfast all or most of time

Cane

Electric lift chair

Hospital bed

Lifted manually

Lifted mechanically

Slide board

Trapeze

Walker

Other-Document Details in Notes

5g. Does the individual need additional assistance in 

managing TRANSFERS?

No

Yes-Document Details in Notes

6a. TOILETING: Ability to manage bowel and bladder 

elimination.

1 - Independent-Skip to 10.A.7a

2 - Limited Assistance

3 - Total Assistance

4 - Self management of indwelling catheter/ ostomy

6b. If Limited Assistance, indicate ALL types needed for 

TOILETING:

Assistance on or off bed pan

Assistance with incontinent products

Assistance with the use of equipment/ assistive devices

Clothing maneuvers/ adjustment

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Personal hygiene post toileting

Setup

Supervision

Transfer to toilet

Other-Document Details in Notes

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6c. TOILETING: Assistance currently provided by what 

INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

6d. TOILETING: Assistance currently provided by what 

FORMAL supports?

None

Aging Programs

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

6e. How often is support available for TOILETING? 

Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

6f. Assistive devices/ adaptive equipment used for 

TOILETING? Document Details in Notes

None

Bed pan/ urinal

Catheter

Commode

Grab bars

Ostomy

Pads for incontinence

Raised toilet seat

Other-Document Details in Notes

6g. Does the individual need additional assistance in 

managing TOILETING?

No

Yes-Document Details in Notes

7a. BLADDER CONTINENCE: Indicate the description 

that best describes the individual's BLADDER function.

1 - Continent - Complete control, no type of catheter or 

urinary collection device

2 - Usually Continent - Incontinence episodes once a 

week or less

3 - Incontinent - Inadequate control, multiple daily 

episodes

4 - Self management of indwelling catheter or ostomy

7b. Does the individual need additional assistance in 

managing BLADDER CONTINENCE?

No

Yes-Document Details in Notes

7c. BOWEL CONTINENCE: Indicate the description that 

best describes the individual's BOWEL function.

1 - Continent - Complete control, no ostomy device

2 - Usually Continent - Incontinence episodes once a 

week or less

3 - Incontinent - Inadequate control, multiple daily 

episodes

4 - Continent - with ostomy

7d. Does the individual need additional assistance in 

managing BOWEL CONTINENCE?

No

Yes-Document Details in Notes

7e. Does the individual use incontinency products?

No

Yes-Document Details in Notes

8a. WALKING: Ability to safely walk to/ from one area 

to another; manage/ use any needed ambulation devices.

1 - Independent-Skip to 11.A.1

2 - Limited Assistance

3 - Total Assistance

8b. If Limited Assistance, indicate ALL types needed for 

WALKING:

Hands on assistance with the use of equipment/ assistive 

devices

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document Details in Notes

8c. Does the individual need additional assistance in 

managing WALKING?

No

Yes-Document Details in Notes

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11. MOBILITY

11.A. INDIVIDUAL'S MOBILITY

1. BEDBOUND: Is the individual bedbound? Indicate in 

Notes any comments or relevant information.

No

Yes-Skip to 12.A.1

Unable to Determine

2a. INDOOR MOBILITY: Ability of movement within 

INTERIOR environment:

1 - Independent-Skip to 11.A.3a

2 - Limited Assistance

3 - Total Assistance

2b. If Limited Assistance, indicate ALL types needed for 

INDOOR MOBILITY:

Assistance with the use of equipment/ assistive devices

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document Details in Notes

2c. Assistive devices needed for INDOOR MOBILITY. 

Document Details in Notes

None

Cane

Hand rails

Hold furniture/ walls

Prosthesis-Document Type in Notes

Quad cane

Scooter

Stair glide

Walker

Wheelchair (manual)

Wheelchair (motorized)

Other-Document Details in Notes

2d. Does the individual need additional assistance in 

managing INDOOR MOBILITY?

No

Yes-Document Details in Notes

3a. OUTDOOR MOBILITY: Ability of movement OUTSIDE 

living arrangement:

1 - Independent-Skip to 11.A.4a

2 - Limited Assistance

3 - Extensive/ Total Assistance

3b. If Limited Assistance, indicate ALL types needed for 

OUTDOOR MOBILITY:

Assistance with the use of equipment/ assistive devices

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Set-up

Supervision

Other-Document Details in Notes

3c. Assistive devices needed for OUTDOOR MOBILITY. 

Document Details in Notes

None

Cane

Hand rails

Holds onto walls

Prosthesis-Document Type in Notes

Quad cane

Scooter

Stair glide

Walker

Wheelchair (manual)

Wheelchair (motorized)

Other-Document Details in Notes

3d. Does the individual need additional assistance in 

managing OUTDOOR MOBILITY?

No

Yes-Document Details in Notes

4a. STAIR MOBILITY: Movement safely up and down 

STEPS:

1 - Independent-Skip to 11.A.5

2 - Limited Assistance

3 - Extensive/ Total Assistance

4b. If Limited Assistance, indicate ALL types needed for 

STAIR MOBILITY:

Assistance with the use of equipment/ assistive devices

Encouragement, cueing, or coaxing

Guided maneuvering of limbs (includes hands on 

assistance)

Independent

Set-up

Supervision

Other-Document Details in Notes

4c. Does the individual need additional assistance in 

managing STAIR MOBILITY?

No

Yes-Document Details in Notes

5. What is the individual's weight bearing status?

Full weight bearing

Partial weight bearing

Toe touch weight bearing

Non-weight bearing

Unable to Determine

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6. Select all that affect the individual's MOBILITY:

None

Ambulation Dysfunction

Aphasia

Fatigues Easily

Muscle Stiffness

Pain

Poor Balance

Rigidity

Shuffling Gait

Spasms

Tremors/ Twitches

Other-Document Details in Notes

11.B. FALLS

1. Is the individual at risk of falling?

No

Yes

Unable to Determine

2. Select the number of times the individual has fallen 

in the LAST 6 MONTHS.

None-Skip to 12.A.1

1

2

3 or More

3. Reasons for falls-Document Details in Notes

Accidental

Environmental

Medical

Other-Document Details in Notes

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12. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)

12.A. IADLs

1. MEAL PREPARATION: Ability to plan/ prepare meals, 

use of kitchen appliances, heat meals. List any needed 

adaptive equipment/ assistive devices in Notes.

1 - Independent-Skip to 12.A.2

2 - Limited Assistance

3 - Total Assistance

1a. MEAL PREPARATION: Assistance is currently 

provided by what INFORMAL supports? Document 

Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

1b. MEAL PREPARATION: Assistance is currently 

provided by what FORMAL supports? Document Details 

in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

1c. How often is support available for MEAL 

PREPARATION? Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

2. HOUSEWORK: Ability to maintain living space, 

includes tasks such as dishwashing, making the bed, 

dusting, running the vacuum or sweeping an area. List 

any needed adaptive equipment/ assistive devices in 

Notes.

1 - Independent-Skip to 12.A.3

2 - Limited assistance

3 - Total Assistance

2a. HOUSEWORK: Assistance is currently provided by 

what INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

2b. HOUSEWORK: Assistance is currently provided by 

what FORMAL supports? Document Details in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

2c. How often is support available for HOUSEWORK? 

Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

3. LAUNDRY: Ability to gather clothes, place clothes in 

washing machine, turn on appliance, remove clothes and 

place in dryer, or hand wash items and hang to dry. List 

any needed adaptive equipment/ assistive devices in 

Notes.

1 - Independent-Skip to 12.A.4

2 - Limited Assistance

3 - Total Assistance

3a. LAUNDRY: Assistance is currently provided by what 

INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

3b. LAUNDRY: Assistance is currently provided by what 

FORMAL supports? Document Details in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

3c. How often is support available for LAUNDRY? 

Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

4. SHOPPING: Ability to go to the store and purchase 

needed items, including groceries and other items. List 

any needed adaptive equipment/ assistive devices in 

Notes.

1 - Independent-Skip to 12.A.5

2 - Limited assistance

3 - Total Assistance

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4a. SHOPPING: Assistance is currently provided by what 

INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

4b. SHOPPING: Assistance is currently provided by what 

FORMAL supports? Document Details in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

4c. How often is support available for SHOPPING? 

Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

5. TRANSPORTATION: Ability to travel on public 

transportation or drive a car. List any needed adaptive 

equipment/ assistive devices in Notes.

1 - Independent-Skip to 12.A.6

2 - Limited Assistance

3 - Total Assistance

5a. TRANSPORTATION: Assistance is currently provided 

by what INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

5b. TRANSPORTATION: Assistance is currently provided 

by what FORMAL supports? Document Details in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

5c. How often is support available for 

TRANSPORTATION? Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

6. MONEY MANAGEMENT: Ability to manage financial 

matters, writing checks, paying bills, going to the bank. 

List any needed adaptive equipment/ assistive devices in 

Notes.

1 - Independent-Skip to 12.A.7

2 - Limited assistance

3 - Total Assistance

6a. MONEY MANAGEMENT: Assistance is currently 

provided by what INFORMAL supports? Document 

Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

6b. MONEY MANAGEMENT: Assistance is currently 

provided by what FORMAL supports? Document Details 

in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

6c. How often is support available for MONEY 

MANAGEMENT? Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

7. TELEPHONE: Ability to obtain phone numbers, dial 

the telephone and communicate with person on the other 

end. List any needed adaptive equipment/ assistive 

devices in Notes.

1 - Independent-Skip to 12.A.8

2 - Limited Assistance

3 - Total Assistance

7a. TELEPHONE: Assistance is currently provided by 

what INFORMAL supports? Document Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

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7b. TELEPHONE: Assistance is currently provided by 

what FORMAL supports? Document Details in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

7c. How often is support available for TELEPHONE? 

Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

8. HOME MANAGEMENT: Ability to perform heavier 

household tasks such as taking out the trash, completing 

minor repairs around the living space, yard work and/ or 

snow removal. List any needed adaptive equipment/ 

assistive devices in Notes.

1 - Independent-Skip to 13.A.1

2 - Limited Assistance

3 - Total Assistance

8a. HOME MANAGEMENT: Assistance is currently 

provided by what INFORMAL supports? Document 

Details in Notes

None

Family

Friend

Neighbor

Other-Document Details in Notes

8b. HOME MANAGEMENT: Assistance is currently 

provided by what FORMAL supports? Document Details 

in Notes

None

Medicaid

Medicare

Hospice

Private Pay Insurance

Other-Document Details in Notes

8c. How often is support available for HOME 

MANAGEMENT? Document Details in Notes

Daily

Weekly

Monthly

Other-Document Details in Notes

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13. NUTRITION

13.A. DIETARY ISSUES

1. Does the individual generally have a good appetite?

No-Document Details in Notes

Yes

Other-Document Details in Notes

2. Does the individual use a dietary supplement?

No

Yes-Document Details in Notes

3. Does the individual have any food allergies?

No

Yes-Document Details in Notes

4. Does the individual have a special diet for medical 

reasons?

No

Yes-Document Details in Notes

5. Does the individual have a special diet for religious/ 

cultural reasons?

No

Yes-Document Details in Notes

13.B. NUTRITIONAL RISK ASSESSMENT

1. Has there been a change in lifelong eating habits 

because of health problems?

No

Yes-Document Details in Notes

2. Does the individual eat fewer than 2 meals per day?

No

Yes-Document Details in Notes

3. Does the individual eat fewer than 2 servings of dairy 

products (such as milk, yogurt, or cheese) every day?

No

Yes-Document Details in Notes

4. Does the individual eat fewer than 5 servings (1/2 

cup each) of fruits or vegetables every day?

No

Yes-Document Details in Notes

5. Does the individual have 3 or more drinks of beer, 

liquor or wine almost every day?

No

Yes-Document Details in Notes

6. Does the individual have trouble eating due to 

problems with chewing/ swallowing?

No

Yes-Document Details in Notes

7. Individual does not have enough money to buy food 

needed?

No

Yes-Document Details in Notes

8. Does the individual eat alone most of the time?

No

Yes-Document Details in Notes

9. Does the individual take 3 or more prescribed or 

over-the-counter drugs (OTC) per day?

No

Yes-Document Details in Notes

10. Has the individual lost or gained at least 10 pounds 

or more in the LAST 6 MONTHS? Document Details in 

Notes (See 9.E.3)

No

Yes, gained 10 pounds or more

Yes, lost 10 pounds or more

Don't know

11. Individual is not always physically able to shop, cook 

and/or feed themselves (or find someone to do it for 

them).

No

Yes-Document Details in Notes

12. Calculates the consumer's Nutritional Risk Score 

based upon the responses to 2.A. 1-11.

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14. INFORMAL SUPPORTS

14.A. INFORMAL HELPER(S) INFORMATION

1. Does the individual have any NON-PAID helpers that 

provide care or assistance on a regular basis?

No-Skip to 14.C.1

Yes-Complete Section 14

2. List names, phone numbers and email addresses of 

the non-paid helpers. Use the Note section if more room 

is needed.

3. Do any of the non-paid helpers reside in the 

individual's home?

No

Yes-Document Details in Notes

4. Select the relationships of the individual's non-paid 

helpers:

Child/ Child-in-Law

Friend

Neighbor

Parent

Spouse/ Domestic Partner

Other-Document Details in Notes

14.B. CONCERNS ABOUT THE HELPING RELATIONSHIPS

1. What concerns does the individual have about any of 

the non-paid helpers? Document Details in Notes

None

Cognition

Doesn't feel safe

Drug/ alcohol abuse

Mental health

Physical health

Regrets actions toward helper when upset

Strained relationship

Stressed/ overwhelmed

Theft of belongings/ money/ assets

Understanding and managing the behavior of the care 

recipient

Understanding and managing the care recipient's health 

needs.

Other-Document Details in Notes

2. Care Manager's observations or concerns about the 

non-paid helpers-Document Details in Notes

None

Cares for others

Displays behaviors that pose a risk to the individual's 

well-being

Family or other responsibilities

Not reliable/ unwilling to provide care

Not Trustworthy

Poor physical health, disabled or frail

Poor relationship/ communication

Possible alcohol/ drug abuse

Possible mental health issues

Other-Document Details in Notes

14.C. ADDITIONAL INFORMAL SUPPORTS

1. Is the individual involved with any informal supports 

in the community that are or may be willing to provide 

help and support (i.e., church, social or community 

organizations)?

No-Skip to 15.A.1

Yes-Complete 14.C.2

2. Document the name of the community support(s), 

type of help and frequency of help that could be or is 

provided.

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15. PROTECTIVE SERVICES (PS)

15.A. PROTECTIVE SERVICES (PS) Questions 1-3 are 

MANDATORY

1. Does the individual feel afraid in his/ her current 

living situation?

No

Yes-Completion of Section 15 is required

2. Is the individual safe to stay in his/ her home 

environment?

No-Completion of Section 15 is required

Yes

3. Does the individual need a safe place to stay?

No

Yes-Completion of Section 15 is required

4. Note any dangers - Document Details in Notes.

None/ Not Reported

Gang Activity

History of Violent Behavior in Home

Known Drug Activity

Neighborhood Dangers

Pets

Weapons

Unknown

Other-Document Details in Notes

5. Is a referral to protective services indicated?

No

Yes-Document Details in Notes

15.B. ACCESS TO SERVICES

1. Does the individual have an issue with access to 

needed services or supports?

No

Yes-Document Details in Notes

2. If the individual does not have access to the needed 

services or supports, what assistance is needed?

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16. PHYSICAL ENVIRONMENT

16.A. CURRENT DWELLING UNIT

1. Does the individual own his/ her current residence?

No-Document Details in Notes

Yes

2. Is the individual able to remain in his/ her current 

residence?

No-Document Details in Notes

Yes

Uncertain-Document Details in Notes

3. What conditions of the home environment cause 

health and safety risks to the individual? Document in 

notes what and where are the problems.

None

Appliances

Clutter

Cooling system

Environmental pests

Furnishings

Hallways

Heating system

Lack of electricity

Lack of fire safety devices

Lack of refrigeration

Lack of toilet

Lack of water

Lighting

Pets

Poor flooring

Shower

Stairs

Structural issues

Other-Document Details in Notes

4. What areas of the home environment impact 

accessibility? Document in Notes, what and where 

problems exist.

Bathroom

Bedroom

Hallways

Home entryways

Kitchen

Laundry

Stairs

Other-Document Details in Notes

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17. EMERGENCY INFORMATION

17.A. EMERGENCY INFORMATION

1. What are the individual's physical limitations that 

would prevent individual leaving the home alone in an 

emergency?

None

Bed bound/ immobile

Dementia (May be reluctant to leave.)

Hearing impaired (May need special warnings.)

Intellectual disabilities (Supervision needed.)

Lives alone (May be reluctant to leave.)

Morbid Obesity

Visually impaired (Guide dogs may become disoriented in 

a disaster.)

Wheelchair bound (Special transportation needed.)

Other-Document Details in Notes

2. Does the individual have any of the following special 

medical needs during a public emergency?

None

Dialysis

Insulin

Life sustaining equipment or treatment

Nasal/ gastrointestinal tubes/ suctioning

Oxygen

Respirator

Special medications & management needs

Specialized transportation

Supervision

Other-Document Details in Notes

3. Select ALL types of Personal Emergency Response 

Systems (PERS) with which the individual is currently 

utilizing:

None

PERS/ w 24 hour family/ designated contact notification

PERS/ w 24 hour response for elopement (GPS)

Other-Document Details in Notes

4. Is the consumer enrolled in a community response 

program?

No

Yes-Document Details in Notes

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18. INDIVIDUAL/ SPOUSE/ HOUSEHOLD FINANCIAL DATA

18.A. INDIVIDUAL'S INCOME

1. Refused to provide financial information?

No

Yes

2. Does the individual have direct deposit?

No

Yes-Document Details in Notes

3. Individual's monthly Social Security (SS) income:

 $

4. Individual's monthly Supplemental Social Security 

Income (SSI):

 $

5. Individual's monthly retirement/ pension income:

 $

6. Individual's interest/ dividends income:

 $

7. Individual's monthly public assistance:

 $

8. Individual's monthly VA benefit income:

 $

9. Individual's monthly black lung income: Do not 

consider this as income for CSP determination.

 $

10. Individual's monthly wage/ salary/ earnings income:

 $

11. Individual's monthly rental income:

 $

12. Individual's railroad retirement benefit income:

 $

13. Individual's annuity, trust, estate income:

 $

14. Reverse mortgage monthly income:

 $

15. Individual's other monthly income-Document the 

source of income in Notes.

 $

16. Individual's Total Monthly Income indicator WILL go 

here. (Until then, manually enter total.)

 $

18.B. INDIVIDUAL'S ASSETS

1. Individual's primary savings account balance:

 $

2. Individual's primary checking account balance:

 $

3. Individual's certificates/ other retirement accounts:

 $

4. Individual's NON-residential real estate assets value:

 $

5. Cash surrender value of the individual's primary life 

insurance policy:

 $

6. Individual's stocks and bonds account balances:

 $

7. Individual's other account(s) balance(s)-Document 

type of account(s) in Notes.

 $

8. Individual's Total ASSETS Value indicator WILL go 

here. (Until then, manually enter total.)

 $

18.C. SPOUSE'S INCOME (RESIDING with Individual)

1. Monthly Social Security (SS) income of spouse 

RESIDING with the individual:

 $

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2. Monthly SSI of spouse RESIDING with the individual:

 $

3. Monthly retirement/ pension income of spouse 

RESIDING with the individual:

 $

4. Monthly interest/ dividend income of spouse 

RESIDING with the individual:

 $

5. Monthly public assistance income of spouse 

RESIDING with the individual:

 $

6. Monthly VA benefits income of spouse RESIDING 

with the individual:

 $

7. Monthly Black Lung income of spouse RESIDING with 

the individual:

 $

8. Monthly wage/ salary/ earnings income of spouse 

RESIDING with the individual:

 $

9. Monthly NON-residential rental income of spouse 

RESIDING with the individual:

 $

10. Other monthly income of spouse RESIDING with the 

individual-Document the source of income in Notes.

 $

11. RESIDING Spouse's Total monthly income 

INDICATOR WILL go here. (Until then, manually enter 

total.)

 $

18.D. HOUSEHOLD INCOME

1. Financial Resources Score - Only required for 

individuals served in community.

Individual Alone Annual $34,470 and Above; W/ Spouse 

$46,530 and Above

Individual Alone Annual $33,033-$34,469; W/ Spouse 

$44,591-$46,529

Individual Alone Annual $31,596-$33,032; W/ Spouse 

$42,652-$44,590

Individual Alone Annual $30,160-$31,595; W/ Spouse 

$40,713-$42,651

Individual Alone Annual $28,724-$30,159; W/ Spouse 

$38,774-$40,712

Individual Alone Annual $27,288-$28,723; W/ Spouse 

$36,835-$38,773

Individual Alone Annual $25,852-$27,287; W/ Spouse 

$34,896-$36,834

Individual Alone Annual $24,416-$25,851; W/Spouse 

$32,957-$34,895

Individual Alone Annual $22,980-$24,415; W/ Spouse 

$31,018-$32,956

Individual Alone Annual $21,544-$22,979; W/ Spouse 

$29,079-$31,017

Individual Alone Annual $20,108-$21,543; W/ Spouse 

$27,141-$29,078

Individual Alone Annual $18,672-$20,107; W/ Spouse 

$25,203-$27,140

Individual Alone Annual $17,236-$18,671; W/ Spouse 

$23,265-$25,202

Consumer Alone Annual $14,364-$15,799; W/ Spouse 

$19,389-$21,326

Consumer Alone Annual $15,800-$17,235; W/ Spouse 

$21,327-$23,264

Consumer Alone Annual $0-$14,363; W/ Spouse 

$0-$19,388

18.E. BENEFIT PROGRAMS

1. Check all benefits the individual is currently 

RECEIVING:

Food Stamps

LIHEAP

Medicaid

PACE

Section 8

Subsidized Transit

Tax and Rent Rebates

Weatherization

Other-Document Details in Notes

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19. NEEDS ASSESSMENT SUMMARY

19.A. LCD & NAT OUTCOME

1. What is the most recent Level of Care Determination 

(LCD) for this individual?

NFCE-Nursing Facility Clinically Eligible

NFCE-No physician document

NFI-Nursing Facility Ineligible

2. Has the individual had a change in condition that 

warrants a new LOC determination?

No

Yes-Document Details in Notes

3. What referral is recommended based on the LCD & 

NAT?

None

CSP-Caregiver Support Program

DC-Domiciliary Care Program

DPW Program

Nursing Home

OPTIONS Program

PCH-Personal Care Home

Other-Document Details in Notes

19.B. NEEDS ASSESSMENT OUTCOME AND 

AUTHENTICATION

1. Name of Care Manager (CM)/ Service Coordinator 

(SC) completing this Needs Assessment Tool

2. Date of Care Manager (CM)/ Service Coordinator (SC) 

Signature

______/______/____________

3. Name of Registered Nurse reviewing the Needs 

Assessment Tool (if reviewed)

4. Date of Registered Nurse review (if reviewed)

______/______/____________

5. Name of Supervisor reviewing this Needs Assessment 

Tool

6. Date Supervisor approved the Needs Assessment 

Tool

______/______/____________

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Title : Date 

Title : Date 

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701D Instructions 

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

Florida Assessment Instructions and Attachments 51
Table	of	Contents

Introduction

Assessor/Case Manager Skills

Completing the DOEA Comprehensive Assessment Instrument 701B

Section A. Demographic Information

Section B. Memory

Section C. General Health, Sensory Function, & Communication Impairment

Section D. Activities of Daily Living (ADL)

Section E. Instrumental Activities of Daily Living (IADL)

Section F. Health Conditions & Therapies

Section G. Mental Health

Section H. Residential Living Environment

Section I. Nutrition

Section J. Medications & Substance Use

Section K. Social Resources

Section L. Caregiver

Attachment A: Social Security Number Handout 

Attachment B: HCE Safety & Accessibility Worksheet 

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Introduction 

The 701B Comprehensive Assessment is the instrument administered in a face-to-face setting to assess 

a client’s health, function, needs, and resources. It is used to complete an initial comprehensive 

assessment and an annual reassessment for clients enrolled in Department-funded case-managed 

programs. It is also completed for active clients who have requested to update their assessment 

information when significant changes take place. CARES assessors use it for individuals who are being 

referred to community placement. The 701B is completed by the Assessor/Case Manager with 

information provided by the client, observed directly, or verified by records. 

The 701D Instructions are a companion manual for the 701B form. To be eligible to administer the 701B, 

staff must complete the web-based 701B Comprehensive Training program and satisfactorily pass the 

competency test. This person will be identified as a certified Assessor or Case Manager, or 

“Assessor/CM,” throughout these instructions, in the training, and on the form. 

These instructions also apply to any questions from the 701B that also appear on the other assessment 

and screening forms, such as the 701A, 701C, and 701S. The purpose of these sub-assessment forms is:

• The 701A form is intended to be administered face to face for non-case managed clients in 

Local Service Programs and Older Americans Act programs.

• The 701C is intended to be administered for congregate meal clients. 

• The 701S is intended to be administered over the telephone for wait list management, initial 

screening, and re-screening of individuals. 

• The 701T is intended to be administered to individuals residing in a nursing facility with no

intent to return to the community or to individuals residing in the community intending to enter 

a nursing facility. 

The Assessor/Case Manager will find it helpful to review the previous assessment prior to 

conducting a reassessment. If any changes are noted during the new interview, the 

Assessor/Case Manager should discuss them with the client or informant to determine the 

effect the changes have on the client’s situation and ability to function. 

Assessor/Case Manager Skills

You will use many skills in conducting assessments. Your observation skills will be necessary to remain 

aware of both the client and your own personal safety at all times. For many assessments, you will be 

meeting a potential or current client in their home. Because residential environments vary widely, you 

should be prepared for a variety of different situations. As you are approaching and entering the 

home, you will need to be aware of your surroundings for your own safety’s sake and make mental 

note of issues surrounding or within the living environment that pose any hazard to the client. 

You will also need your social skills to develop rapport with clients and their families. Prior to beginning 

an interview, take a little time to establish a friendly conversation with the client, caregiver, and other

informants who may be present. Developing rapport will make the interview go more quickly and be 

more productive and enjoyable. If the client feels comfortable, they will speak more openly and allow

you to gather valuable information. 

You will need your professionalism and preparedness skills to conduct assessments. Different topics are 

covered on the comprehensive form, many of which are private or sensitive. For this reason, it is 

important to be familiar with administering the form, to let clients know that a range of topics will be 

covered, and to be prepared to assure clients of the confidentiality of your discussion. It can often help 

put clients at ease to introduce yourself in a friendly conversation; however, remember that once you 

begin the assessment, conversation should feel slightly more formal, like a structured interview. Asking 

the questions as they are written helps convey your professional role and helps gather more reliable 

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information. You should read the questions and answer choices aloud and then look up for the client 

to respond, prompting when necessary. 

Many of our potential and existing clients come from diverse backgrounds and have had a rich variety 

in the life experiences that they bring to their interactions with others. The services and supports that 

clients may need require that we have a basic understanding of their personal habits, customs, and 

practices so that we are able to identify any deficits in their care. Although it is understood that all 

people have personal beliefs, as a representative of your employer, you are expected to comport 

yourself as an unbiased professional in all your interactions with clients. As such, you must reserve any 

personal judgments that are beyond the scope of assessing an individual’s functional limitations. Within 

your ability, you should attempt to understand and accommodate the specific cultural needs of clients 

and their families where applicable. 

Completing the DOEA Comprehensive Assessment Instrument 701B

Florida Department of Elder Affairs

701B Comprehensive Assessment

Rule: 58-A-1.010, F.A.C.

Provider ID: This is the CIRTS Provider ID of the agency employing the Assessor/Case Manager who is 

completing the assessment. If a provider does not have a CIRTS Provider ID, the name of the agency 

must be entered. There is no Provider ID when the assessment is completed by CARES.

Provider Assessor/CM ID: This is the CIRTS worker ID of the Assessor or Case Manager (CM) completing 

the assessment. If the person assessing the client does not have a CIRTS worker ID, the name of the 

worker must be entered. There is no Provider Assessor/CM ID when the assessment is completed by 

CARES.

Questions that begin with the notation “ASSESSOR/CM” and appear in bold text should 

be completed by the Assessor/Case Manager without asking the client or informant for a 

direct response. These are questions that require staff observation or information that staff 

can provide without client assistance.

 

Assessor/CM Name and Signature: This space is for the legibly printed name of the Assessor/Case 

Manager along with her/his signature. The signature at the beginning of the form indicates that the 

Assessor/Case Manager is taking responsibility for the completion of the entire form in a factual and 

objective manner. 

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1. ASSESSOR/CM: What is the purpose of this assessment?: Mark the appropriate box for the purpose 

of conducting the assessment. The Assessor/Case Manager should indicate whether the 

assessment is an initial comprehensive assessment or an annual reassessment. For any assessment 

that is being completed more frequently than every 12 months, the Assessor/Case Manager must 

identify the significant change that is prompting the unscheduled reassessment. Common 

significant changes in client status that might necessitate an unscheduled reassessment include the 

loss of the caregiver, a change of caregiver, a change of residence, or a change in the client’s 

medical condition or financial situation. 

2. Social Security Number (SSN): Enter the client’s Social Security number in the space provided. This is 

a nine-digit number. A “unique identifier” for each client is used for tracking and comparing 

information. 

Under Title 42, Code of Federal Regulations, Section 435.910, Assessors/Case Managers are 

authorized to collect client SSNs to determine benefits or services that may be appropriate for the 

client. However, to comply with s. 119.071(5), Florida Statutes, all clients shall be provided a 

written statement that explains their SSN is confidential under law and that disclosure of their SSN 

is voluntary. You will bring printed copies of Attachment A to provide to the client for their 

information and reference. 

If a client does not wish to release her/his SSN, a nine-digit pseudo ID will automatically be created by 

CIRTS using the following formula: Use the initials from the client’s name (first, middle or “X,” and last) 

for the first three characters. If the middle initial is unknown, then enter “X.” Enter the client’s six-digit 

date of birth (MM/DD/YY) to create the last six characters. Do not make up a DOB. 

For example: Ellen Elizabeth Hyatt; DOB: January 5, 1912. Pseudo ID would be = EEH010512 

3. Name: Obtain the client’s full name (first, middle initial, and last) and note it in the spaces

provided. If the client does not have a middle initial, leave the space blank.

4. Medicaid Number: If the client is receiving general Medicaid or services under one of the Medicaid 

waivers, s/he will have a ten-digit Medicaid number assigned by the Department of Children and 

Families (DCF). Enter the client’s Medicaid number in the space provided. The client will not have a 

Medicaid number while their Medicaid application is in a pending status. 

If a person is receiving Supplemental Security Income (SSI) through the Social Security 

Administration, s/he will also be eligible for Medicaid and will have a Medicaid number 

assigned by DCF.

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5. Phone Number: Note the client’s area code and primary phone number, if there is a phone, in the 

space provided. The phone number includes the area code and the seven-digit phone number. If 

the client does not have a phone, leave the item blank. If the client also has a mobile phone, ask 

for the number that is the best way to reach them and note the other in the “Notes & Summary” 

section.

6. Date of Birth: In the space provided, note the client’s date of birth in a two-number format for the 

month (i.e., February would be ‘02’). Likewise, use the two-number format for the day (i.e., the third 

of the month would be ‘03’) and a four-number format for the year (i.e., 2013) as indicated by 

“mm/dd/yyyy” throughout the form. 

7. Sex: Mark the appropriate box to indicate whether the client identifies themselves as female or 

male. 

8. Race: Obtain the client’s response and mark the box or boxes, as applicable, to indicate the 

client’s race. Clients may provide more than one response. These categories are consistent with 

federal reporting requirements: 

• “White” 

• “Black/African American”

• “Asian” 

• “American Indian/Alaska Native”

• “Native Hawaiian/Pacific Islander”

• “Other” (Any other racial group not coded above). 

9. Ethnicity: Obtain the client’s response and mark the appropriate box to indicate the client’s 

ethnicity. “Hispanic/Latino” is the only ethnicity required for federal reporting. A person who 

identifies as Hispanic or Latino may be from any racial group. If it is needed information for service 

referrals, use the space provided in the “Notes & Summary” section to indicate what culturally 

specific accommodations may be necessary.

10. Primary Language: Mark the appropriate box to indicate the primary language spoken by the 

client. If collected in advance of the assessment during the screening process, this information

may enable the agency to send a worker to the home or arrange for someone who will be able 

to communicate most effectively with the client. 

• “English”

• “Spanish”

• “Other” (Any other language). 

Write-in a brief description of the client’s primary 

language if it is not English or Spanish, and note 

if an accommodation or translator is necessary 

in the “Notes & Summary” section.

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11. Limited English Proficiency (LEP): Mark the appropriate box to indicate whether the client has 

limited ability to read, write, or speak in the English language, or to understand spoken 

English ("No" or "Yes"). This can be due to the client's primary language being other than 

English, literacy issues, or physical impairments. This is not meant for clients who understand 

English, but are deaf or hard of hearing. 

Collecting information about client English proficiency is a federal reporting measure 

and is specifically relevant to the client’s ability to be understood during the 

assessment and care planning process; however it is also relevant to whether they 

can communicate well enough to obtain assistance when needed from others. The inability to 

speak, read, and write in English can be a barrier to managing day to day tasks for many 

people for many reasons. The absence of these basic communication skills becomes a major 

hardship to those who rely on others to assist them for activities of daily living or in unplanned or 

emergency events such as hurricanes, floods, or other natural disasters. If you have LEP clients, 

be sure to discuss with them and their families having a plan to address this limitation for 

emergency situations, and note what kind of accommodation they need for future assessments 

or emergency situations in the “Notes & Summary” section.

12. Marital Status: Select from the listed options. Obtain the client’s response and mark the 

appropriate box to indicate the client’s current marital status: 

• “Married:” An individual who has a legal husband or wife.

• “Partnered:” An individual who is in a relationship with a person, other than a legal spouse.

• “Single:” An individual who has never been married.

• “Separated:” An individual who is legally married, but is living apart from their spouse.

• “Divorced:” An individual whose marriage has been legally dissolved.

• “Widowed:” An individual whose spouse died while they were still married.

13. ASSESSOR/CM: Current Physical Location Address: Note the address of the client’s current physical 

location, including the a. street, b. city, and c. ZIP code in the appropriate spaces. Also, enter the

d. type of physical location and, if appropriate, e. facility name: 

• “Private residence:” The client’s home or the home of another person; not a facility.

• “ALF:” Any state licensed assisted living facility.

• “Nursing facility:” A freestanding facility, certified by AHCA to provide skilled nursing services.

• “Hospital:” An institution that provides care for acute illnesses.

• “Adult Day Care:” A facility which provides less than 24-hour care for eligible adults.

• “Other” (Any other facility not coded above)

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14. Home Address: Note the home address, including the a. street, b. city, and c. ZIP code. The home 

address is where the client maintains their belongings or a home they would return to if they could 

be discharged from a facility. It may be the same as current physical location; if so, you may leave 

it blank and indicate in CIRTS that the address of the current physical location should be copied 

into the home address fields. 

15. Public Housing: Mark the appropriate box to indicate whether the client’s home address is 

currently in public housing (“No” or “Yes”). 

 

Public housing information is an important factor in care planning. For example, a low-income 

client may need information about housing or referral to more affordable or subsidized 

housing. Or, if the client is currently in subsidized housing, restrictions about modifications or 

services may apply that could impact the ability of the client to remain in this setting.

16. Mailing Address: Note the mailing address, including the a. street, b. city, c. state, and d. ZIP code

if different from the address of the client’s current physical location. This is especially important for 

the Home Care for the Elderly (HCE) program since this is the address to which the caregiver’s 

basic subsidy is mailed. You may leave this item blank on the forms, if the client does not have a 

mailing address that is different from their current location. 

There are three different location and address fields on the forms and in the CIRTS database 

because many of the clients we assess are in a period of transition in their lives. For example, we 

may need a current location address because we have to assess someone in a temporary 

location like a rehabilitation facility, their home address so that we know what local providers are 

available for home and community care once they are discharged, and a mailing address, such 

as a P.O. Box. 

17. ASSESSOR/CM: Assessment Date: The assessment date is the date the assessment is completed by 

the Assessor/Case Manager. In the space provided, record the date in a two-number format for 

the month, two-number format for the day, and a four-number format for the year, as indicated 

by “mm/dd/yyyy” throughout the form.

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18. ASSESSOR/CM: Assessment Site: The assessment site is where the assessment is taking place. Mark 

the appropriate box for the site at which the assessment is taking place: 

• “Home:” The client’s home or private residence (not a facility).

• “ALF:” Any state licensed assisted living facility.

• “Nursing facility:” A freestanding facility that is certified under Medicare/Medicaid to provide 

skilled nursing.

• “Hospital:” An institution that provides care for acute illnesses. 

• “Adult day care:” A facility which provides less than 24-hour care for eligible adults.

• “Other” (Any other site not coded above).

19. ASSESSOR/CM: Referral Date: The referral date is the date that the referral was received at the 

receiving agency from the referral source. There may be an earlier date on a referral form, but the 

responsibility begins when the information is actually received. Enter the referral date in the space 

provided. Record the date in this format: mm/dd/yyyy. 

20. ASSESSOR/CM: Referral Source: The referral source is the person or agency making the referral for 

an assessment or services. A referral can be received from any source. Mark the appropriate box

of the source of the referral: 

• “Self/Family:” The client has referred him or herself or the client’s family has referred him/her. 

• “Nursing facility:” A freestanding facility that is certified under Medicare/Medicaid to provide 

skilled nursing. 

• “Case management agency:” An agency that provides case management services.

• “CARES:” Comprehensive Assessment and Review for Long-Term Care Services.

• “Aging out:” CCDA Aging Out of the Community Care for Disabled Adults Program or HCDA 

Aging Out of the Home Care for Disabled Adults Program.

• “Hospital:” An institution that provides care for acute illnesses is making the referral.

• “Department of Children and Families.” 

• “Other” (Any other referral source not coded). 

• “APS:” Adult Protective Services; Abuse/Neglect/Exploitation at DCF is making the referral. 

Note the level of risk as High, Intermediate, or Low. “High Risk” referrals are tracked to ensure 

that the persons are contacted and begin to receive needed services (besides case 

management) within 72 hours of the receipt of the referral. “High Risk” referrals from APS are 

given first consideration for services.

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21. ASSESSOR/CM: Transitioning Out of a Nursing Facility: Mark the appropriate box to indicate 

whether the client has a desire to transition out of a nursing facility (“No” or “Yes”). “Nursing home 

transition” is the voluntary transfer of an individual from a nursing facility to a community setting 

such as a family member’s home, the individual’s apartment or home, an assisted living facility, or 

an adult family care home. Individuals transitioning out of a nursing facility may also include those 

in a nursing or rehabilitation facility on a short-term basis. A referral from CARES may be for a client 

who is transitioning out of a nursing facility. 

22. ASSESSOR/CM: Imminent Risk of Nursing Home Placement: Mark the appropriate box to indicate 

whether the client is in imminent risk of nursing home placement (“No” or “Yes”). 

An imminent risk designation is also used for certain clients transitioning out of a nursing home. 

A referral from CARES or a lead agency may be for a client who is at imminent risk of nursing 

home placement or for someone transitioning out of a nursing home. Refer to the imminent risk 

policy of the Department. It must be followed for all imminent risk designations.

23. Outside Assistance to Evacuate: Mark the appropriate box to indicate whether the client needs 

outside assistance to evacuate during emergencies (“No” or “Yes”). If the individual is able to 

evacuate the home or has arrangements with a caregiver or another person to help them to 

evacuate, then outside assistance is not needed. This question determines if there is a need for 

assistance to be set up by the Assessor/Case Manager. 

24. Special Needs Registry: Mark the appropriate box to indicate whether the client is registered with 

the County Special Needs Registry (“No” or “Yes”). Each county in Florida has a listing of persons 

who have disabilities or health conditions that make it vital for them to receive help with 

evacuation during emergencies. Ensuring that clients with evacuation needs are on the county 

listing is a function of the Assessor/Case Manager. 

For clients in a facility of any kind (nursing home, assisted living facility, adult family care 

home, hospital, etc.), the response will be “No,” and the evacuation needs will be the 

responsibility of the facility not the county emergency staff.

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25. Is There a Primary Caregiver: Mark the appropriate box to indicate whether there is a Primary 

Caregiver (“No” or “Yes”). A primary caregiver is defined as any person who regularly can be 

depended on to provide or arrange help as needed with Activities of Daily Living (ADLs) and 

Instrumental Activities of Daily Living (IADLs). This person:

• May or may not be related by birth or marriage;

• May or may not live with the client or live nearby; and, 

• Does not include operators of assisted living facilities, nursing homes, adult family care home 

sponsors, home health agencies, service provider staff or other paid care providers. 

26. Living Situation: Mark the appropriate box to indicate the client’s current living situation (“With 

primary caregiver” (as defined above), “With other caregiver,” “With other,” “Alone”). If the client 

is in a facility, the response would be “Alone.” 

27. Individual Monthly Income: Income information is needed to give the Assessor/Case Manager an 

idea of whether the individual might qualify financially for Medicaid services so that appropriate 

referrals will be made. Indicate the client’s gross monthly income in the space provided. Include 

income from Social Security, SSI, money received from family on a regular basis, pension, 

retirement, savings, disability or veteran’s assistance benefits, earnings from employment, rental 

income, etc. 

Clients may be unable or unwilling to provide individual or couple income and asset 

information. If a client refuses to give this information, check the “Refused” box and 

advise them that they will need to plan to provide it to DCF in order to determine their 

eligibility for Medicaid.

28. Couple Monthly Income: Indicate the client’s gross monthly “couple” income, if applicable, in the 

space provided. Couple Income is only counted for persons who are married and living together. 

If a client refuses to give this information, check the “Refused” box. If the client is not currently 

married/living with a spouse, check the “N/A” (not applicable) box. 

29. Estimated Total Individual Assets: Asset information is needed to give the Assessor/Case Manager

an idea of whether the individual might qualify financially for Medicaid services so that 

appropriate referrals will be made. In the space provided, indicate the client’s estimated total 

assets, excluding the worth of the client’s home, one car, and $2,500 in designated burial assets. If 

the client cannot or will not provide a specific figure, give the three ranges and ask which range 

the assets would fall within: “$0 to $2,000,” “$2,001 to $5,000,” “$5,001 or more.” If a client refuses to 

give this information, check the “Refused” box. 

If the individual has over $2,000 in individual assets, or a couple has $3,000 in combined 

assets, they will generally not qualify for Medicaid waiver programs. However, there are 

some exceptions where the asset limits are slightly higher in limited Medicaid programs. 

So, even if the individual assets are over the asset limit, it does not automatically disqualify 

the individual from receiving needed services. Only DCF can make the final financial 

determination for Medicaid.

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30. Estimated Total Couple Assets: In the space provided, indicate the client’s estimated total

“couple” assets, excluding the worth of the couple’s home, one car, and $5,000 in designated 

burial assets. Next, indicate which of three categories best represents the client’s couple 

assets. If the client cannot or will not provide a dollar figure, give the three ranges and ask 

which range the assets would fall within, marking the box that is applicable (“$0 to $3,000,” 

“$3,001 to $6,000,” “$6,001 or more”). If a client refuses to give this information, check the 

“Refused” box. If the client is not currently married/living with a spouse, check the “N/A” (not 

applicable) box. 

31. Are You Receiving S/NAP (Food Stamps)?: Mark the appropriate box to indicate whether the 

client is currently receiving S/NAP (Supplemental Nutritional Assistance Program) (“No” or “Yes”). 

This is an important referral opportunity for those clients who are food insecure or do not have 

enough income to buy the food that they need. Supplemental nutrition assistance programs are

usually easy to qualify for and can make a huge difference in the monthly grocery bill, yet these 

programs are widely under-utilized in many areas.

32. Do You Need Other Assistance for Food? Mark the appropriate box to indicate whether the client 

needs other assistance for food (“No” or “Yes”). The client may not be eligible for S/NAP (Food 

Stamps) but still need help in obtaining food. Other sources of food assistance could be local food 

pantries, religious groups, or service organizations.

33. ASSESSOR/CM: Client Answering Questions? Mark the appropriate box to indicate whether 

someone besides the client is providing answers to the questions in the assessment (“No” or “Yes”). 

• If someone else is not providing answers (“No”), skip a-b. 

• If someone else is providing answers (“Yes”), indicate the name of the person as well as their 

relationship to the client in spaces a. and b.

There are several places on the form where you will ask clients and caregivers to identify 

other people in their lives and the nature of their relationship. The reason you ask for this 

information is because it is important to identify all the potential resources a client and a 

caregiver may have, what their level of involvement is with the client’s care, and what their 

commitment is to meeting the client’s needs should they be called upon to help. 

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34. Children the client lives with and provides care for: Indicate the total number of children, besides 

the client’s own children, under age 19 that live with and are cared for by the client by entering a 

number on the line provided. 

• If the response is zero, skip a-c.

• If the response is one or more, enter the number and name(s) in items a-c.

• If any number response is zero in a-c, leave the name(s) blank.

Since many people enjoy discussing the little ones in their lives, some Assessors/Case Managers 

recommend using information about kids and grandkids to help establish rapport with clients.

35. Disabled adults the client lives with and provide care for: Indicate the total number of disabled 

adults, aged 19 to 59 that live with and are cared for by the client by entering a number in the 

box provided.

• If the response is zero, skip a-c.

• If the response is one or more, enter the number and name(s) in items a-c.

• If any number response is zero in a-c, leave the name(s) blank.

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701D InstructionsSection B. Memory Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

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Section	B.	Memory

The items in this section are intended to determine the client’s attention, orientation, and ability to 

register and recall new information. These items are crucial factors in many care planning decisions.

 Awareness of possible impairment may be important for maintaining a safe environment.

 A client’s performance on cognitive tests can be compared over time to identify a decline in 

their cognitive abilities.

Direct, performance-based testing of cognitive function decreases the chance of incorrect 

labeling of memory issues and cognitive ability. However, be aware that some clients may 

appear to be cognitively impaired, but are instead experiencing symptoms from other 

factors - such as extreme fatigue, hearing impairment, or emotional or psychological issues. 

Conversely, some clients may appear more cognitively aware than they actually are, or they 

may have cognitive issues that are infrequent, more episodic in nature, or only evident when 

triggered by particular stimuli. 

Introduce this section by telling the client that you are going to ask some questions about their

memory. Explain that the questions will test their ability to remember certain items and determine 

their ability to carry out daily activities. If the client is not giving full attention to the questions being 

asked, you may need to remind them to remove any source of distraction that may impair their 

ability to answer the questions accurately. It may also be necessary to remind anyone else who 

might be sitting in the room during the assessment that the responses to the memory questions must 

come from the client alone.

36. Medical Diagnosis of Memory Issues: The purpose of this question is to determine whether the 

client has been officially diagnosed with any type of memory problem. This is meant to make you 

aware of any formal diagnosis of a decline in memory or cognitive function based on an 

evaluation by a doctor, therapist, nurse, or memory disorder specialist. Indicate the answer to the 

question by marking the appropriate box (“No” or “Yes”).

37. If the Client is Not Answering Questions: If someone other than the client is answering the 

questions, check the box on Question 37, skip Questions 38- 46, respond to Question 47, and then 

proceed to the next section of the 701B form (Section C). 

Clients may not always be able to answer the questions in an assessment, and the reasons why 

they are unable to do so will vary. However, some sections of the assessment are only appropriate 

for the client to respond to, like memory tests and mental health screening. So, when the client is 

unable to participate in the assessment, you will simply check the indicator box circled in the 

example above and move on to the next section.

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38. Three-Word Recall, Part 1: As indicated by the quotation marks, the Assessor/Case Manager

should say this exact phrase to the client – “I am going to say three words for you to remember. 

Please repeat the words after I have said them. The words are: Sock (something to wear), Blue (a 

color), and Bed (a piece of furniture). Now you tell me the three words.” If the interview is being 

conducted with an interpreter present, the interpreter should use the equivalent words and similar, 

relevant prompts for category cues. 

Assessor/Case Managers need to use the exact words and related category cues as

indicated. Category cues serve as a hint that helps prompt clients’ recall ability. Putting words 

in context stimulates learning and fosters memory of the words that clients will be asked to 

recall later, even among clients able to repeat the words immediately.

After the client’s first attempt to repeat the items, you will check off the words that the client 

repeats, and then indicate the total number of correct words repeated by the client. The words 

may be recalled in any order and in any context. So, it is allowable for the words to be repeated 

back in a different order or in a sentence format, like “I sat on the bed to put on my blue sock.” Then 

the client would be credited with repeating all the words. If the client correctly stated all three 

words, simply say: “Thank you. I will ask you to repeat these again to me later.” However, if the client 

recalled two or fewer words, you are permitted to prompt them with: “Let me say the three words 

again. They are sock, something to wear; blue, a color; and bed, a piece of furniture. Now, will you 

repeat those three words for me?” 

If the client still does not recall all three words correctly, you may repeat the words and category 

cues for a third time. However, the number of repeated words on the second or third attempt are all 

scored zero. These attempts help the client with learning the item, but only the number of words 

recalled correctly on the first attempt goes into the total score.

39. Current Year (Long-term Temporal Orientation): Ask the client to indicate what year it is. Allow up 

to 30 seconds for an answer and do not provide clues. If the client specifically asks for clues (e.g., 

“Is the election this year?”), respond by saying: “I need to know if you can answer this question 

without any help from me.” You might also have to remind the client that they cannot look at a 

newspaper or anything else to help them with the response.

• “Correct:” If the client provides a correct response

• “Missed by 1 year:” If the client’s response is within one year of the current year

• “Missed by 2-5 years:” If the client’s response is within two to five years of the current year

• “Missed by 5+ years:” If the client’s response is more than five years from the current year

• “No answer:” The client cannot or chooses not to answer the item

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40. Current Month (Long-term Temporal Orientation): Ask the client to indicate what month it is. Allow

up to 30 seconds for an answer and do not provide clues. If the client specifically asks for clues 

(e.g., “Is my birthday this month?”), respond by saying: “I need to know if you can answer this 

question without any help from me.” You might also have to remind the client that they cannot 

look at a newspaper or anything else to help them with the response.

• “Correct:” If the client provides a correct response

• “Missed by 1 month:” If the response is within one month of the current month

• “Missed by 2-5 months:” If the response is within two to five months of the current month

• “Missed by 5+ months:” If the response is more than five months from the current month

• “No answer:” The client cannot or chooses not to answer the item

41. Current Day of the Week (Short-term Temporal Orientation): Ask the client to indicate what day of 

the week it is. Allow up to 30 seconds for an answer and do not provide clues. If the client 

specifically asks for clues (e.g., “Is it bingo day?”), respond by saying: “I need to know if you can 

answer this question without any help from me.” You might also have to remind the client that 

they cannot use other clues to help them respond (e.g., looking at the newspaper, calendar on 

the wall, television, etc.)

• “Correct:” If the client provides a correct response

• “Incorrect:” If the client provides an incorrect response

• “No answer:” The client cannot or chooses not to answer the item

42. Three-Word Recall, Part 2: Ask the client – “Let’s go back to an earlier question. What were those 

words I asked you to repeat back to me?” Allow up to 5 seconds for spontaneous recall of each 

word. Mark the words that the client recalls. 

It is important to ask the three-item recall question in the order it is given and within the 

established time frame to get an accurate reflection of the client’s recall ability. If the 

interview is interrupted for longer than a few minutes between initial and follow-up questions, 

the three-item recall test is invalid. If this happens, be sure to leave the responses blank on 

the form and include this information in the “Notes & Summary” section.

43. Words Recalled without Prompting: Indicate the total number of words (on a scale of 0-3) that the 

client recalled without any prompting and without you providing any hints or any cues. 

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44. Concern from Friends/Family about Memory: Indicate whether the client’s friends or family 

members have expressed concern about his or her memory (“No” or “Yes”). 

Family and friends may be hesitant to directly express concern about a client’s memory 

loss or cognitive problems. So instead they show this concern indirectly by asking questions 

about whether the client is managing their personal affairs properly. You may need to 

provide clients with examples, such as: “Do your friends or family members call to ask 

about how often you are eating or showering?” or “Do they double check the tasks you 

perform, like balancing the checkbook or making sure you locked the door when you

leave the house?”

45. Client Concern about Memory: Indicate whether the client has become concerned about their

memory, or had problems remembering details about things that are normally important to them 

like birthdays, appointments, plot lines to favorite television shows, etc. (“No” or “Yes”). If the client 

has not become concerned about his or her memory, or had problems remembering important 

things (“No”), skip Question 46. 

46. Frequency of Memory Problems: If the client indicates that they have become concerned about

having memory problems, next indicate how often the client has problems remembering things: 

“Always,” “Often,” “Sometimes,” “Rarely,” or “Don’t know” as appropriate.

47. Cognitive Problems Present: Based on the client responses to the preceding questions in Section B, 

this is where the Assessor/Case Manager should provide her/his opinion of whether cognitive 

problems are present. 

• “No:” Client answered questions appropriately and accurately.

• “Yes:” Client has demonstrated, been diagnosed, or has disclosed problems with memory, 

thinking, judgment, or orientation to time/place/people.

• “Don’t know:” The Assessor/Case Manager could not determine if cognitive problems were 

present. 

Throughout the assessment form, you will see “Notes & Summary” sections provided for 

you to jot down any relevant elaborations or details that may assist you with determining 

level of care and designing the care plan. Document issues not covered by the 

questions on the form or document discussions you have had with the client, family, 

and/or facility about problems you observe.

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701D InstructionsSection C. General Health, Sensory 

Function & Communication Impairment

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

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Section	C.	General	Health,	Sensory	Function	&	Communication	Impairment

The items in this section are intended to determine the client’s perception of their general health, 

sensory health and function, and identify any communication impairments or accommodation 

needs. In the exceptional event that the client is unable to answer the questions, consult with a 

caregiver, health care provider, or other informant to fill out the form. Then note that the client did 

not provide answers, identify the source of the information in the “Notes & Summary” section, and 

include this in the case narrative for this visit.

48. Overall Health: This item is meant to be a subjective reflection by the client about their overall 

opinion of their own health. This opinion can be relative to other people, relative to their own 

history, or without any qualification. 

A client’s self-perception can either boost or undermine her/his health and 

independence. If the answers to Questions 48 or 49 are negative, it is important to 

use these questions as an introduction to a broader conversation about what the 

client has gone through over the past year. For example, if the client states their 

health is worse, ask what has changed and for examples of how this change has 

affected their daily activities and ability to care for her/himself.

49. Health Compared to One Year Ago: This item is meant to be a subjective reflection by the client 

about their opinion of their own health relative to their own health a year ago. This item should 

give you some perspective on their progress or decline over the course of the last year.

50. Fear of Falling: People with a history of falling may limit activities because of a fear of falling and 

should be evaluated for reversible causes of falling. Moreover, when an individual fears falling, 

they often self-restrict the activities they engage in outside the home, which can severely diminish 

the amount of interactions they have with friends, family, and support networks. 

51. Six Month History of Falls: This question counts any fall, no matter where it occurred. Record the 

total number of falls in the appropriate box.

A “fall” is an unintentional change in position coming to rest on the ground, floor, or onto the 

next lower surface (e.g., onto a bed, chair, or bedside mat). Falls are not a result of an

overwhelming external force (e.g., a client being pushed by someone else). An intercepted fall 

occurs when the client would have fallen if s/he had not caught her/himself or had not been 

intercepted by another person – this is still considered a “fall” for purposes of the assessment. 

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52. Limitations from Physical Problems: This item captures the range of activities and tasks that speak 

to the client’s overall goals for their life. This information should assist in care planning and in 

evaluating satisfaction with services at reassessment.

53. Medical Care Availability: Medical care refers to treatment and care provided by doctors, nurses, 

and therapists at the hospital, clinic, office, or other location. 

54. Transportation to Care is Readily Available: This item is meant to include any means of 

transportation that the client is able to arrange on their own. Explain this does not include calling 

911.

55. Drive a Car/Motor Vehicle: Indicate the client’s response to this question by marking the 

appropriate box (“No” or “Yes”). Driving a car should never prevent someone from receiving 

services. 

Many times clients drive out of necessity, whether or not it is still safe or appropriate for them to 

do so in all circumstances. If the client says ‘yes,’ but is very frail or has disclosed memory or 

vision problems, the Assessor/Case Manager may ask the client if anyone has suggested they 

no longer drive or may suggest they discuss with their doctor whether or not they should 

continue driving.

56. Finances Permit Access to Health Care and Medications: This item refers to the client’s overall 

ability to afford treatment that can be achieved in combination with insurance and other means.

57. ER/Hospital Visits in Last Year: Ask and record the approximate number of times the client visited 

the emergency room or was admitted to the hospital in the past 12 months. 

An ER visit is counted when the client visits the ER and is not admitted to the hospital. A hospital 

admission is counted when the client is admitted to the hospital from the ER or community. If the 

client visits the ER and is hospitalized from there, it is counted as only one event: a hospital 

admission, not two events: an ER visit and a hospital admission.

58. Nursing Facility or Rehabilitation Facility stays: Ask and record if the client has been admitted to a 

nursing home or rehabilitation facility in the last 12 months. 

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59. Ability to Climb Steps: This refers to the client’s usual ability, not their abilities on their worst day or 

best day. The ability to climb stairs is not covered by walking/mobility in the ADL section; so if the 

client is unable to climb stairs and has stairs in the home, this could indicate a safety or care plan 

issue.

60. Assessor/Case Manager: Are there stairs in or leading to the dwelling: This question is for you to 

respond to with your own observation or recollection regarding the presence of a change in 

elevation that requires traversing stairs. For clients with any noted impairment to their mobility, it is 

especially important that you note the presence of stairs that may inhibit the client from accessing 

important areas of their residence and evacuating the dwelling if necessary. 

61. Ability to Carry a Glass of Water: This refers to their usual ability to perform the task, not on their 

worst day or their best day. The ability to carry a glass of water is a measure of grip strength, 

balance, steadiness of gait, and overall function. This is not covered in the IADL section; so if the 

client is unable to carry a glass of water, this could indicate an independence barrier or a need to 

be addressed in the care plan. 

If the client is unable to walk steadily or maintain enough grip strength to carry a glass of 

water, it could indicate a dehydration risk or indicate a barrier to preparing meals. In some 

clients, grip can be improved with supports in the care plan, like occupational therapy, and 

supported with assistive devices to restore the client’s ability to prepare meals and other 

tasks.

62. Vision Problem Diagnosis: Indicate the client’s response to this question by marking the 

appropriate box (“No,” “Yes,” or “Blind”). If the client has been diagnosed as totally blind, you 

may skip questions a., b., and c. Be aware that acute or profound vision loss may limit the client’s 

ability to manage personal business requiring reading or signing documents, such as checks or 

consent forms.

a. Eye exam in the past year: Indicate the client’s response in the appropriate box (“No” or “Yes”).

b. Bump into objects (i.e., people, doorways) because you don’t see them: Indicate the client’s 

response by marking the appropriate box (“No” or “Yes”).

c. Vision getting worse than it was last year: Indicate the client’s response by marking the 

appropriate box (“No,” “Only in one eye,” “Slightly worse,” or “Much worse,” as appropriate).

Although many people minimize or joke about sensory impairments, problems like vision loss are

serious and may be a symptom of a major illness or threaten independence. If uncorrected, vision 

impairment can limit a client’s ability to participate in both functional and pleasurable activities, with 

profound impact to their quality of life. Fortunately, vision loss can often be improved with treatment. 

So, if the client indicates to you that they are experiencing some recent vision loss, refer them to be 

screened or ask them to make an appointment to have it checked by a doctor.

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63. Hearing Problems: Indicate the client’s response to this question by marking the appropriate box 

(“No,” “Yes,” or “Deaf”). If the client has been diagnosed as totally deaf, skip a., b., and c. 

a. Hearing exam in the past year: Indicate the client’s response by marking “No” or “Yes.” 

b. Understand words clearly over the telephone: Indicate the client’s response by marking “No” or 

“Yes.” (Note, if the client answers “no”, a sensory device may be helpful.)

c. Hearing worse than it was last year: Indicate the client’s response by marking “No,” “Only in 

one ear,” “Slightly worse,” or “Much worse,” as appropriate.

Like other sensory impairments, hearing loss should be treated seriously. It may contribute to a 

client’s feelings of social isolation, exacerbate some mood and/or behavioral disorders, and can 

even be mistaken for cognitive or memory impairment. Fortunately, hearing loss can often be 

improved with treatment. If the client indicates they are experiencing some hearing loss, refer them 

to be screened or ask them to make an appointment to see their doctor to have it checked.

If you suspect or are told that a client has hearing loss, it is important to determine if they 

hear and understand the assessment questions. If they are having a hard time hearing, 

you should face them directly, ask them to turn up the volume on any hearing aids, turn 

off competing noise from the television or radio. You may also need to speak louder and

more slowly or more clearly enunciate unexpected words. 

64. ASSESSOR/CM: Non-verbal Communication: Indicate whether the client relies on writing, gestures, 

or signs to communicate by marking the appropriate box (“No” or “Yes”). If yes, please indicate if 

the client has developed means or devices to assist communication with others, like TTY for the 

telephone, etc. in the “Notes & Summary” section.

65. ASSESSOR/CM: Speaking Ability: Indicate whether the client’s words are formed properly, not 

slurred or clipped, by marking “No” or “Yes.” It is important for basic as well as emergency 

communication for clients to be comprehensible - so note if detectable speech impairment is 

minor or major.

Note that slurred speech can be an indicator of acute health problems, such as recent stroke, 

head injury, extreme fatigue, dehydration, mismanaged medications, mouth or tooth problems.

It is important to discuss speech impairment with the client and/or caregiver to determine if this 

is a new occurrence. Recent deterioration in a client’s ability to speak or enunciate words should 

be brought to the immediate attention of a physician.

Florida Assessment Instructions and Attachments 73
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

6	 DOEA	701D,	General	Health,	Sensory	Function	&	Communication	Impairment,	Revision 071213

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66. ASSESSOR/CM: Sensory Aids/Assistive Devices: Indicate whether the client currently uses any 

sensory aids or assistive devices by marking the appropriate box (“No” or “Yes”), and if yes, list the 

type(s) in the space provided. 

A sensory aid is a small object that can be worn or held by the user to improve a sensory 

deficit, such as a hearing aid, glasses, magnifying glass, etc. A sensory device is a larger 

object or article of technology that assists the user by intensifying images and sounds, or 

translates cues into a more detectable format (e.g., amplifiers, buzzers, flashing lights, etc.) 

67. ASSESSOR/CM: Unmet Need for Sensory Aids/Assistive Devices: Indicate whether the client has an 

unmet need for a sensory aid or assistive device by marking the appropriate box (“No” or “Yes”). If 

there is an unmet need (“Yes”), describe the types of aids or devices needed in the text box.

Florida Assessment Instructions and Attachments 74
701D InstructionsSections D & E. Activities of Daily Living & 

Instrumental Activities of Daily Living

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

Florida Assessment Instructions and Attachments 75
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

2	 DOEA	701D,	ADL	&	IADL,	Revision	071213

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Section	D. Activities	of	Daily	Living	(ADL)

The items included in this section identify the client’s ability to functionally perform the tasks needed to 

maintain a healthy and independent life, and the amount of assistance with personal care tasks that 

the client is currently receiving from others. Activities of Daily Living (ADL) measure self-care tasks. The 

objective of this assessment is to determine what additional assistance the client may need to 

function as normally and independently as possible. To introduce this section, explain to the client that 

you are going to ask some questions about her/his ability to do a list of personal care activities. Ask 

whether s/he needs help in performing each activity, and explain the tasks that each activity includes 

by reviewing the definition on the form with the client. The possible answers are on the form and 

repeated below. Read all of the choices verbatim and ask the client to select one. Do not assume the 

answer for the client, or attempt to infer it from your earlier conversations. 

If the client seems to be self-conscious discussing personal care problems, you may need 

to reassure them of your confidentiality and underscore the importance of identifying all of 

their impairments. You might say something like: “I understand that these topics might 

make you uncomfortable, but I assure you that I speak to a lot of people with many 

different needs and have probably heard it all. The better I understand the kind of specific 

limitations you have, the more helpful I can be to you.” For more information, you can also 

refer to the “Asking Difficult Questions” module of the web-based 701B training program.

If the client gives you a response that you have reason to disagree with, or if you strongly suspect that 

the client has given an incorrect response or is masking her/his inability, you may need to make a 

determination based on other sources or your own observation. For example, the client states that 

s/he needs no assistance using the bathroom, but you notice the client has difficulty in walking, is 

wearing soiled clothing, has a strong body odor, or you detect a urine odor in the house. You ask the 

client directly about these observations but s/he denies any issue. Your recourse is to seek information 

about the client’s ability from a caregiver, family member or other informant. In the absence of 

information from others, you make the determination of the client’s capacity in the answer choice for 

the question, and note the discrepancy between the client’s response and your observations in the 

“Notes & Summary” section to include in the case narrative for this visit. 

Florida Assessment Instructions and Attachments 76
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

3	 DOEA	701D,	ADL	&	IADL,	Revision	071213

68. Activities of Daily Living (ADLs): Ask the client how much assistance s/he needs with completing

the tasks listed on the form for activities a-f, and determine the amount of help needed from the 

following range: 

• “No assistance needed:” Indicates that client needs no help to perform any part of the activity. 

• “Uses assistive device:” Indicates that the client needs an assistive device or technology to 

complete the activity. 

• “Needs supervision or prompt:” Indicates that the client needs reminders or supervision during 

the activity. Otherwise s/he needs no physical help to perform the activity. 

• “Needs assistance (but not total help):” Indicates that the client needs hands-on physical help

during part of the activity. 

• “Needs total assistance (cannot do at all):” Indicates that the client cannot complete activity 

without total physical assistance. 

Assistive devices* for Activities of Daily Living include, but are not limited to:

Bathing Shower stool, long-handled sponge, removable shower head 

sprayer

Eating Suction-bottomed bowls and plates, wide-handled utensils

Transferring from bed or chair Grab bars, non-slip mats, bed lifts or rails

Dressing Buttoning claws, Velcro closures, zipper pulls or extender tabs

Toileting/using the bathroom Hand-rails, seat lifts, spray or squirt bottles

Walking/mobility Walker, cane, motorized chairs or lifts, ramps

*For other examples and images of devices, please refer to the web-based comprehensive assessment training.

For both ADLs and IADLs, a client can use or need a device AND need some help from a 

person. Therefore you may need to check both boxes. For example, a client may use grab bars 

to steady themselves while they take a shower and also require supervision or prompt to 

remember or to properly complete the task of bathing. For that client, you would check the box 

for “Uses an Assistive Device” AND check the box that they require “Needs Supervision or 

Prompt.” 

Activities of Daily Living include the following tasks and examples:

a. Bathing: Bathing includes running the water, taking the bath or shower, and washing all parts of 

the body, including hair. Note whether deficits are the result of mental impairment, physical 

limitations, or environmental barriers. 

b. Dressing: Dressing includes getting out clothes, putting them on, taking them off and 

fastening/unfastening them; it also includes putting on shoes. 

c. Eating: Eating includes eating, drinking from a cup, and cutting foods. 

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d. Using the bathroom: Using the bathroom independently includes adjusting clothing, getting to 

and on the toilet, cleaning oneself and getting off the toilet. If a client can manage without an 

accident alone, they are independent. 

Incontinence accidents can be hard for some people to discuss. For more information on ways 

you can be more at ease with this and other sensitive topics, please refer to the “Asking Difficult 

Questions” module of the web-based 701B training program.

e. Transferring: Transferring is defined as getting in and out of a bed or chair. Make a mental note

to observe the client actually demonstrating this ability and whether s/he needed a device to 

do so. 

f. Walking/Mobility: Independence in walking refers to the ability to walk short distances at home, 

but it does not include the ability to climb stairs. Note whether the client actually demonstrated 

this ability and whether s/he needed a device or some help to do so. 

69. Unmet Need for ADL Assistive Device: Is there a need for assistive devices to help the client to 

handle her/his ADL functions? If there is no unmet need, mark “No.” If there is an unmet need, 

mark “Yes” and indicate the specific devices needed in the text box. 

The questions in the assessment about “unmet needs” are referring to the individual 

needing a device that s/he does not currently have, but may benefit from. Notes about 

what devices are already in use should be made in the “Notes & Summary” section on 

the form or in the client’s case narrative for the visit. 

SCENARIO EXAMPLE: SCORING CLIENT DRESSING ASSISTANCE NEEDS

How much assistance do you need with dressing? 

No 

assistance 

needed Uses 

assistive 

device Needs 

supervision

or prompt Needs 

some 

assistance

Needs

total 

assistance, 

cannot do

at all

Client is able to get their clothes out of the closet, 

put them on unassisted, fasten/unfasten clothing 

articles, and put on their own socks and shoes.



Client is able to perform all parts of dressing activities because 

of the use of an assistive device(s), such as Velcro tabs on 

shoes and zipper pulls on pants. 



Client is able to perform all parts of dressing activities listed above if 

another person is there during the activity to lend support by her/his 

presence or to coach the client through the activity, without any handson assistance being given.



Client is able to perform some parts of the dressing activities listed above and needs 

hands-on assistance. This may be a small amount of assistance, such as putting on the 

client’s shoes, or may be a lot of assistance, such as holding up the clothing for the

client to step into and fastening all the closures. 



If client is unable to perform any part of the dressing activities and another person is needed to 

perform the activity for them. This level of help would be for a client who must rely on someone to 

select the clothing, put it on and take it off their body, fasten all buttons, snaps and zippers, and 

put on the client’s shoes. 



Florida Assessment Instructions and Attachments 78
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

5	 DOEA	701D,	ADL	&	IADL,	Revision	071213

70. Assistance with Activities of Daily Living (ADLs): Assessing the frequency a client has assistance 

with a task is different from identifying how much assistance the client needs. You will ask the client 

how much assistance they have with completing the tasks listed on the form for activities a-f, and 

determine the frequency of help they have from the following range: 

• “No assistance needed:” Indicates that client receives no help from others because they do 

not need any help to perform any part of the activity. 

• “Always has assistance:” Indicates that the client always has an adequate level of help to 

meet their need in performing the activity.

• “Has assistance most of the time:” Indicates that the client usually has the help they need to 

perform the activity, or more often than not they have an adequate level of help for the 

activity. 

• “Rarely has assistance:” Indicates that the client has unpredictable, unreliable or seldom has 

the amount of assistance they need to complete the activity. 

• “Never has assistance:” Indicates that the client has absolutely no assistance to complete the 

activity. 

EXAMPLE: SCORING CLIENT DRESSING RESOURCES

How much assistance do you have with 

dressing? 

No 

assistance 

needed

Always has 

assistance Has 

assistance 

most of the 

time Rarely has 

assistance

Never has 

assistance

Client is able to dress appropriately for the 

weather and circumstances without any 

prompt or supervision. Client is able to put on 

and take off clothing, socks, and shoes

without any assistance. 



If client has a responsible and reliable source of daily 

assistance that helps with any part of the activity, as the 

client’s needs dictate.



If client has assistance that meets the majority of their needs. “Most of 

the time” can mean that they have help on either most of the days or 

every day but only with most of the activities involved with the task. 



If client has infrequent or unreliable assistance with dressing needs. This is scaled to 

what they need - so if they only need a reminder that it is cold outside and to wear a 

sweater when they go to church, and they have help once a week, then they always

have assistance. However, if they need help putting on pants every day, but they 

only have help to get dressed once a month, then they would rarely have assistance.



If client is unable to perform the dressing activity and another person is never available to assist 

with what articles are needed for the weather or occasion and manage their daily putting on and 

removal of clothing and shoes. This could be a client who “needs total assistance” or a client who 

only “needs some assistance” or needs prompting, as long as they never have the assistance they 

need. 



Florida Assessment Instructions and Attachments 79
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

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Section	E.	Instrumental	Activities	of	Daily	Living	(IADL)

Instrumental Activities of Daily Living (IADL) included in this section identify the client’s ability to 

complete moderately complex tasks that are generally necessary in daily life to maintain 

independence. These items are also thought of in terms of the client’s ability to function in relation to 

the general community. The objective of this section is to determine what assistance the client needs 

with key tasks that enable him/her continue to function as normally and independently as possible. 

To introduce this section, explain to the client that you are going to ask some questions about her/his 

ability to do a list of specific activities. Ask whether s/he needs help in performing each activity, and 

explain the tasks that each activity includes by reviewing the definition on the form with the client. The 

possible answers are on the form and repeated below. Read all of the choices verbatim and ask the 

client to select one. Do not assume the answer for the client, or infer it from your conversation. 

In the rare event that the client gives you a response that you have reason to disagree with, or if you 

strongly suspect that the client has given an incorrect response or is masking her/his inability; you may 

need to collect input from other sources like a caregiver, family member or other informant, or you 

may need to make a determination based on your observation of the client’s performance of the 

task. If you score a client’s functioning differently than they would have scored themselves, you will 

make a note of this discrepancy between the client’s response and your observations in the “Notes & 

Summary” section to include in the case narrative for this visit. 

With repetitive daily activities, deficits in the adequacy of assistance a person receives 

can occur for some tasks but not others, due to variance in the frequency a task needs 

to be completed in a day, week or month. So, for example, your client tells you that they 

have assistance for an hour once a day for any task they need help with. That means 

that some task needs will be adequately met, while other tasks will need additional 

assistance to be adequately fulfilled. For example, some ADLs are high frequency needs, 

like being mobile and able to ambulate frequently throughout the day. Likewise for 

IADLs, most people need to prepare meals to eat and may need to manage 

medications several times a day. However, most people will only need to transfer and 

dress twice daily, do shopping or light housekeeping a few times a week, and have

transportation to go to appointments or have the lawn mowed a few times a month. 

Florida Assessment Instructions and Attachments 80
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

7	 DOEA	701D,	ADL	&	IADL,	Revision	071213

71. Instrumental Activities of Daily Living (IADLs): Ask the client how much assistance s/he needs with 

completing the tasks listed on the form for activities a-h, and determine the amount of help 

needed from the following range: 

• “No assistance needed:” Indicates that the client needs no help to perform any part of the 

activity.

• “Uses assistive device:” Indicates that the client needs an assistive device or technology to 

complete the activity. Remember, a client may use a device and also require assistance from 

a person to complete a task. So, when applicable, both the assistive device box and an 

assistance needed box may be checked for a single task. For example, a client may need a 

pill minder to track their medications, and they may also require their caregiver to pick up their 

medications from the pharmacy for them. That client would have both “Uses Assistive Device” 

and “Needs Assistance (but not total help)” checked.

• “Needs supervision or prompt:” Indicates that the client needs reminders or supervision during 

the activity. Otherwise s/he needs no physical help to perform the activity. 

• “Needs assistance (but not total help):” Indicates that the client needs hands-on physical help

during part of the activity. 

• “Needs total assistance (cannot do at all):” Indicates that the client cannot complete the 

activity without total physical assistance. 

*For other examples and images of devices, please refer to the web-based comprehensive assessment training.

Assistive devices* for Instrumental Activities of Daily Living include, but are not limited to:

Heavy Chores Grabber, extension poles, non-skid bumpers, slider pads

Light Housekeeping Grabber, extension poles, specialty appliances

Using the Telephone Extra-large buttons, amplifier on the handset, light-up ringer

Managing Money Extra signers or other account safeguards

Preparing Meals Rubber-grip utensils, edge guards or suction-grip bowls and 

plates, stools or chair 

Shopping Electric cart, in-store assistive technology like order-ahead or carside service

Managing Medications Pill-minder, reminder alarms or phone service, pill crusher or sleeve

Using Transportation Chair lifts, stabilizers, rubberized mats, ramps, extra mirrors, seat 

lifts 

Florida Assessment Instructions and Attachments 81
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

8	 DOEA	701D,	ADL	&	IADL,	Revision	071213

Instrumental Activities of Daily Living include the following tasks and examples: 

a. Heavy Chores: These chores may include yard work, washing windows, moving furniture, doing 

laundry, etc. Laundry includes putting clothes in the washer or dryer, starting and stopping the 

machine, and drying the clothes. Hand washing of clothes and line drying are also included. 

(Laundry is still authorized as a homemaker service. It is included under heavy chores in these 

instructions as the best match with Administration on Aging definitions of services.) 

b. Light Housekeeping: Light housekeeping includes dusting, vacuuming, and sweeping. If the 

client needs help, record who helps and how housekeeping tasks are done. 

c. Using the telephone: This activity may include the use of an amplifier or special equipment. If the 

client requires special equipment, describe what is needed. If the client can use the telephone 

independently but is slow to answer or unable to use a dial phone, note this also.

d. Managing money: Managing money includes paying bills and balancing a checkbook. If the 

client needs help, identify the person who manages the client’s financial affairs.

e. Preparing meals: Preparing meals is making sandwiches, cooking meals, and heating frozen 

meals. If the client needs help, describe how her/his meals are obtained.

f. Shopping: This is the ability to shop for food and other things needed but is not managing 

transportation. 

g. Managing medication: This is the ability to take one's own medication. Indicate how the client 

manages her/his medication regimen, either with a personal reminder system or with assistance 

from others. 

h. Using Transportation: This is the ability to use local transportation or to drive to places beyond 

walking distance. You should record the client’s main source of transportation. 

SCENARIO EXAMPLE: SCORING CLIENT MEDICATIONS MANAGEMENT ASSISTANCE NEEDS

How much assistance do you need with managing 

medications?

No 

assistance 

needed Uses 

assistive 

device Needs 

supervision

or prompt Needs 

some 

assistance

Needs

total 

assistance, 

cannot do

at all

If client is able to take medications as prescribed by 

a doctor or as instructed on an over-the-counter 

package.



If client is able to perform all parts of the taking medication 

activity because of the use of an assistive device(s), such as 

use of a pill minder or other helping device that the client fills 

her/himself.



If client is able to perform all parts of the taking medication activity listed 

above if another person is there during the activity to lend support by 

her/his presence or to coach the client through the activity, without any 

hands-on assistance being given.



If client is able to perform some parts of the taking medication activity listed above 

and needs another person to be present during the activity to lend some hands-on 

assistance. This may be a small amount of assistance, such as filling the pill minder for 

the client, or may be a lot of assistance, such as actually handing the pills to the client.



If client is unable to perform the taking medication activity and another person is needed to 

perform the activity for them. This level of help would be for a client who must rely on someone to 

administer medications, including such action as putting the pill in the client’s mouth, holding the 

water, and rubbing the client’s throat to assist with swallowing. 



Florida Assessment Instructions and Attachments 82
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

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72. Unmet Need for IADL Assistive Device: Is there a need for assistive devices to help the client to 

handle her/his IADL functions? If there is no unmet need, mark “No.” If there is an unmet need, 

mark “Yes” and indicate the specific devices needed in the text box. This question is referring to 

the individual needing a device that s/he does not have. Notes about what devices are already 

in use should be made on the form or in the client’s case narrative for the visit. 

73. Assistance with Instrumental Activities of Daily Living (IADLs): Assessing the frequency a client has 

assistance with a task is different from identifying how much assistance the client needs. You will 

ask the client how much assistance they have with completing the tasks listed on the form for 

activities a-h, and determine the frequency of help they have from the following range: 

• “No assistance needed:” Indicates that client receives no help from others because they do 

not need any help to perform any part of the activity. 

• “Always has assistance:” Indicates that the client always has an adequate level of help to meet 

their need in performing the activity.

• “Has assistance most of the time:” Indicates that the client usually has the help they need to 

perform the activity, or more often than not they have an adequate level of help for the 

activity.

• “Rarely has assistance:” Indicates that the client has unpredictable, unreliable or seldom has 

the amount of assistance they need to complete the activity. 

• “Never has assistance:” Indicates that the client has absolutely no assistance to complete the 

activity. 

Florida Assessment Instructions and Attachments 83
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

10 DOEA	701D,	ADL	&	IADL,	Revision	071213

Scoring Instrumental Activities of Daily Living Resources: 

a. Heavy Chores: Record how often the client receives help with heavy chores like yard work, 

washing windows, moving furniture, doing laundry, etc. Also record who helps and which tasks 

are done for the client.

b. Light Housekeeping: Record how often the client receives help with housekeeping tasks like 

dusting, vacuuming, and sweeping. Also record who helps and which tasks are done for the 

client.

c. Using the telephone: Record how often the client receives help from another person to use the 

telephone to make or receive calls (do not include the use of an assistive device like an 

amplifier or other special equipment unless it requires another person to put it in place for the 

client). Examples of assistance using the telephone include keeping track of numbers, dialing, 

holding the phone, etc. If the client can use the telephone independently but is slow to answer 

or unable to use a dial phone, make a note of this also.

d. Managing money: Record how often the client receives help managing their money, paying 

bills, balancing a checkbook, or other monetary matters. Also record who helps and which 

tasks are done for the client.

e. Preparing meals: Record how often the client has assistance with meeting their multiple daily 

meal requirements. Common examples include family members preparing simple meals like 

making a sandwich or heating up a frozen dinner, caregivers who prepare separate 

components of meals that the client uses to assemble into meals later, and neighbors that 

provide “plates” for the client comprised of leftover food from their own meals. Also record 

who helps and which tasks are done for the client.

f. Shopping: Record how often the client has the help they need when shopping for food and 

other items. This does not include transportation to and from the store, but rather refers to the 

assistance drafting a shopping list, selecting items from the shelves, purchasing them and 

unloading them from the car into the home. Also record who helps and which tasks are 

done for the client.

g. Managing medication: Record how often the client has help managing a medication 

regimen, this includes taking their medication as prescribed, filling prescriptions, and 

monitoring why and under what circumstances medications are properly taken. Also record 

who helps and which tasks are done for the client. 

h. Using Transportation: Record how often the client has help with their main source of 

transportation- this could include using local transit options like cabs, shuttles, and busses, or 

simply how often someone helps the client by driving them to the places they need to go. 

Also record who helps and which tasks are done for the client. 

Florida Assessment Instructions and Attachments 84
701D	Instructions	for	DOEA	701B	Comprehensive	Assessment,	July	2013

11 DOEA	701D,	ADL	&	IADL,	Revision	071213

EXAMPLE: SCORING CLIENT MEDICATIONS MANAGEMENT RESOURCES

How much assistance do you have with 

managing medications?

No 

assistance 

needed Always has 

assistance Has 

assistance 

most of the 

time Rarely has 

assistance

Never has 

assistance

If client is able to take medications as 

prescribed by a doctor or as instructed on 

an over-the-counter package. 



If client has a responsible and reliable source of daily 

assistance that helps with any part of the activity, as the 

client’s needs dictate.



If client has assistance that meets the majority of their needs. “Most of 

the time” can mean that they have help on either most of the days or 

every day but only with most of the activities involved with the task. 



If client has infrequent or unreliable assistance with medications. This is scaled to what 

they need - so if they only need a pill minder filled once a week, and they have help 

once a week, then they always have assistance. However, if they need that pill 

minder filled once a week, but they only get help to fill it once a month, then they 

would rarely have assistance.



If client is unable to perform the managing medication activity and another person is needed to 

remember what ailments are treated with which prescriptions, arrange to have the medications 

refilled as needed, and manage their daily administration and other aspects of completing the 

task. 



Florida Assessment Instructions and Attachments 85
701D InstructionsSection F. Health Conditions & Therapies

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

Florida Assessment Instructions and Attachments 86
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2	 DOEA	701D,	Health	Conditions	&	Therapies,	Revision	071213

Section	F.	Health	Conditions	&	Therapies

This section helps to generate an updated, accurate picture of the client’s current health status and 

need for medical treatment and therapies. The items in the first half of this section are intended to 

document diagnosed past or current health conditions that have a direct relationship to the client’s 

current functional status, behavior, medical treatments, or risk of death. It is understood that the

presence of several major or many minor health conditions such as those listed in this section can 

have a significant adverse effect on an individual’s health status, quality of life, and level of assistance 

they need to function. 

74. Health Conditions: Ask the client whether they have been told by a physician that they currently have

or ever have had any of the health conditions listed. The Assessor/Case Manager should review the 

entire list with the client and have the client stop to discuss each condition they have or have had that 

is listed on the form. If the client indicates that s/he had the condition in the past, mark the first box 

(“Past”). If the client indicates that s/he currently has the condition (or is still affected by the condition), 

mark the second box (“Current”). In addition, specific information is requested with certain conditions. A 

list of each condition is provided on the form, and a discussion of each is provided in the following list. 

For more information on the region, symptoms, and etiology of these diseases, please consult the webbased 701B comprehensive training. 

• Acid reflux/GERD (Gastroesophageal reflux disease) – A condition in which the stomach contents (food 

or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the 

stomach). This action can irritate the esophagus, causing heartburn and other symptoms.

• Allergies – Indicate the types of allergies the client has/had. Allergic reactions occur when a person’s 

immune system reacts to normally harmless substances in the environment or diet. For example: hay 

fever, hives, insect stings, mold, latex, sulfa, penicillin, dairy, wheat, peanuts, etc.

• Amputation – Indicate the site of the amputation(s). Amputation is the removal of a limb, or part of a 

limb, that is no longer useful and causing great pain, or threatens a person’s health because of extreme 

infection. For example: leg, arm, foot, etc. Be sure to indicate if it is the right or left arm, etc. Most people 

who require an amputation have Peripheral Artery Disease (PAD), a traumatic injury, or cancer.

• Anemia – Indicate whether the condition is/was: severe, moderate, or mild. Anemia is a condition in 

which the body does not have enough healthy red blood cells, which provide oxygen to body tissues.

The lack of oxygen may cause a person to feel tired, the heart may beat too quickly and may cause 

chest pain and dizziness. The lack of oxygen to the brain may cause a person to feel confused, have a 

headache and have cold hands and feet.

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• Arthritis – Indicate the type of arthritis the client has/had. For example: osteoarthritis, rheumatoid arthritis, 

gout, psoriatic arthritis, lupus, etc. Arthritis is the inflammation of one or more joints. A joint is the area 

where two bones meet. Arthritis involves the breakdown of cartilage, which normally protects a joint, 

allowing it to move smoothly and to absorb shock when pressure is placed on the joint. Without the 

normal amount of cartilage the bones rub together causing pain, swelling (inflammation), and stiffness.

• Bed sore(s) (Decubitus) – Indicate the location of the bed sore(s) the client has/had. For example:

spine, coccyx (tailbone), hip, heel, elbow, ankle, etc. Decubitus is an ulceration of tissue deprived of 

adequate blood supply by prolonged pressure. Pressure sores/bed sores are grouped by their severity.

Stage I is the earliest stage, and Stage IV is the worst. Stage I: reddened area when pressed does not 

turn white. Stage II: skin blisters or forms an open sore. Stage III: skin develops an open, sunken hole 

called a crater. Stage IV: ulcer is so deep that there is damage to the muscle and bone, and sometimes 

to tendons and joints.

• Blood pressure – Indicate whether the client has/had high or low blood pressure. Blood pressure is the 

pressure exerted by circulating blood upon the walls of blood vessels and is one of the principal vital 

signs.

• Broken bones/fractures – Indicate the location of the fractures the client has/had. For example: hip, leg, 

arm, ankle, etc. Be sure to indicate if it is/was the left or right hip, etc.

• Cancer – Indicate the site of the cancer the client has/had. Examples: lung, bone, breast, prostate

• Chlamydia - A bacterial sexually transmitted disease (STD) known as a “silent disease” because 75 

percent of infected women and at least half of infected men carry the disease without recognizing any 

symptoms. When symptoms occur, they most often appear within 1 to 3 weeks of exposure. Symptoms 

for women may include abnormal vaginal discharge, burning when urinating, low back pain, nausea, 

fever, pain during sexual activities and general lower abdominal pain. Symptoms for men may include 

discharge from penis, burning when urinating, and pain and swelling in the testicles.

Older people are less likely to use condoms than other age groups, both because they do not 

consider themselves to be at risk of pregnancy and they were not a target for the national 

efforts in education that protection from STDs should be part of their sex lives.

• Cholesterol – Indicate whether the client has/had high or low cholesterol. Cholesterol is an organic 

chemical substance classified as a waxy steroid of fat. Although it is important and necessary for human 

health, high levels of cholesterol in the blood have been linked to damage to arteries and 

cardiovascular disease. Low cholesterol could increase the risk of some health problems.

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• Dehydration – Occurs when you lose more fluid than you take in and your body does not have enough 

water and other fluids to carry out its normal functions. Dehydration is a major health risk in hot climates 

and is a leading cause for emergency hospitalization in the elderly. Dehydration can lead to serious 

complications, including: falls, heat injury, swelling of the brain, seizures, low blood volume shock, kidney 

failure, coma and death.

• Diabetes (IDDM/NIDDM) - IDDM refers to insulin-dependent diabetes mellitus. NIDDM refers to noninsulindependent diabetes mellitus. Diabetes is a lifelong (chronic) disease in which there are high levels of 

sugar in the blood. People with diabetes have high blood sugar because their body cannot move 

sugar into fat, liver, and muscle cells to be stored for energy. This is because either their pancreas does 

not make enough insulin, their cells do not respond to insulin normally, or both. Symptoms of high blood 

sugar levels may include: blurry vision, excessive thirst, fatigue, frequent urination, hunger, and weight 

loss. Having diabetes can complicate other medical issues.

• Dizziness – Indicate whether the client’s dizziness is/was: constant, frequent, occasional, or rare. Dizziness 

is a term used to describe everything from feeling faint or lightheaded to feeling weak and unsteady.

Dizziness that creates the sense that you or your surroundings are spinning or moving is called vertigo.

• Fibromyalgia – Is a common syndrome in which a person has long-term, body-wide pain and 

tenderness in the joints, muscles, tendons, and other soft tissues. Fibromyalgia has also been linked to 

fatigue, sleep problems, headaches, depression, and anxiety.

• Gallbladder – Indicate whether the client had her/his gallbladder removed or has/had problems. The 

gallbladder is a pear-shaped organ under the liver. It stores bile, a fluid made by the liver to digest fat.

The gallbladder releases bile through a tube called the common bile duct to aid in digestion. The 

gallbladder is most likely to cause trouble if something blocks the flow of bile through the bile ducts; 

usually the blockage is due to a gallstone. Signs of a gallbladder attack may include nausea, vomiting, 

or pain in the abdomen, back, or just under the right arm.

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Asking a client about sexually transmitted diseases such as Chlamydia, Gonorrhea, and 

Herpes may seem intrusive; however, it is imperative to gather this information for the following 

reasons:

 To properly recognize a medical condition. For example, the symptoms might be related to the 

manifestation of a sexually transmitted disease instead of another medical condition.

 To provide appropriate treatment. Many primary care physicians do not discuss these issues with 

disabled and elderly patients, and as a result these diseases go untreated for longer periods of time.

 To educate the client of risks associated with sexual behaviors. Many clients were never educated 

about the use of condoms in sexual activity to prevent the spread of disease.

 To inform caregivers or other personnel of possible contagious conditions in order to ensure 

additional precautions are taken.

 To monitor the course of the disease. For example, a client with untreated syphilis in the late stage 

may not have symptoms until 20 years after infection; these symptoms can lead to paralysis, 

blindness, dementia, and even death.

 To mitigate the interaction with other diseases. Sexually transmitted diseases can greatly complicate 

or worsen other medical conditions. For example, the treatment of a bed sore is complicated by a 

herpes outbreak.

 To determine the reason for the client’s functional limitations. Mobility can be impaired by disease 

symptoms and therefore can be restored with proper identification and treatment.

• Gonorrhea – A bacterial sexually transmitted disease (STD), characterized by a white, yellow, or green 

discharge or an itching or burning sensation when urinating or defecating, occurs in the genital area, 

mouth, or throat, and is spread from person to person through skin-to-skin contact.

• Heart problems (Pacemaker, CHF, MI, etc.) – Heart disease is a broad term used to describe a range of 

diseases that affect the heart. These include: diseases of the blood vessels, such as coronary artery 

disease (CAD); heart infections; heart defects that people are born with (congenital heart defects); 

and heart rate or rhythm problems called arrhythmias. During an arrhythmia, the heart can beat too 

fast, too slow, or with an irregular rhythm. A pacemaker is a small device that is placed in the chest or 

abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart 

to beat at a normal rate. Congestive heart failure (CHF) means your heart cannot pump enough blood 

to meet your body’s need; symptoms may include fatigue and weakness; swelling (edema) in the legs, 

ankles, and feet; sudden weight gain from fluid retention; and swelling of the abdomen (ascites).

Myocardial infarction (MI), or “heart attack,” occurs when a blood clot blocks the flow of blood through 

a coronary artery. Symptoms vary, but may include shortness of breath, sweating, fainting, nausea, 

vomiting, and increasing episodes of chest pain. 

• Head, brain, or spinal cord trauma – Traumatic brain injury is sudden physical damage to the brain. The 

damage can result from a closed head injury, such as that caused by impact of the head with an 

object like the windshield or dashboard of a car. The damage can also result from a penetrating brain 

injury, such as that caused by a bullet piercing the skull. Traumatic spinal cord injury is damage to the 

spinal cord that results in loss of mobility or feeling. In most cases, the spinal cord remains intact, but the 

damage results in loss of nerve function.

• Herpes – A viral sexually-transmitted disease (STD), characterized by episodic outbreaks of sores or 

lesions in the genital area, that through touch can be spread to any orifice (eyes, nose, mouth).

• Human Immunodeficiency Virus (HIV) – A viral disease, characterized by compromised immune 

functions, slow wound healing, skin degradation, and fatigue. It can be spread by blood-to-blood 

contact of any kind, including sexual contact, needle sharing from drug use, piercings or tattoos, and in 

rare cases, from improperly screened blood transfusions or tissue donations. 

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• Human Papilloma Virus (HPV)/Genital warts – A viral sexually-transmitted disease (STD), characterized by 

few symptoms other than small bumps in the genital area, mouth or throat. It can be spread from 

person to person through skin-to-skin contact. 

• Incontinence, Bladder – Indicate whether the client’s bladder incontinence is: constant, frequent, 

occasional, or rare. Urinary incontinence is the inability to control the release of urine from your bladder.

There are different types of urinary incontinence: stress incontinence is loss of urine when coughing, 

sneezing, laughing, etc.; urge incontinence is a sudden, intense urge to urinate followed by an 

involuntary loss of urine; overflow incontinence is frequently or constantly dribbling urine; mixed 

incontinence is having symptoms of more than one type of urinary incontinence; functional 

incontinence is when a physical or mental impairment prevents you from getting to a toilet on time; 

total incontinence is continuous leaking of urine, day and night, or the periodic uncontrollable leaking 

of large volumes of urine.

• Incontinence, Bowel – Indicate whether the client’s bowel incontinence is: constant, frequent, 

occasional, or rare. Bowel incontinence (fecal incontinence) is the inability to control your bowel 

movements, causing stool (feces) to leak unexpectedly from your rectum. Fecal incontinence ranges 

from an occasional leakage of stool while passing gas to a complete loss of bowel control in someone 

who is older than four years old.

Although it is typically thought of as a symptom in the very frail, clients of all ages, conditions, 

and level of health may have problems managing incontinence. In particular, you should be 

aware that experiencing bladder and bowel incontinence can be very difficult for some people 

to handle emotionally, interpersonally, and socially. As a result, it has been linked to issues like 

homeboundedness, deterioration in perceived social support, decreased physical activity, and 

caregiver burnout. In an effort to minimize episodes and avoid purchasing incontinence 

supplies, some people attempt to manage incontinence with lifestyle changes, such as 

restricting fluids, delaying or skipping meals if away from home, and other individualized 

strategies. Unfortunately those efforts can have unintended physical consequences like 

dehydration, urinary tract infection, constipation, and others. 

• Kidney problems or renal disease – Indicate whether the condition is end stage. End Stage Renal 

Disease (ESRD) is the complete or almost complete failure of the kidneys to work. Other kidney problems 

include: Chronic Kidney Disease (CKD); blood in the urine (hematuria); protein in the urine (proteinuria); 

kidney stones, etc. Kidney problems may have no symptoms until the disease is very far along and may 

include nausea; fatigue; dizziness; swelling in feet, hands, or face; back pain; high blood pressure; 

bloody, foamy or dark-colored urine. If diseases and symptoms persist without treatment, permanent 

kidney damage or failure may result. 

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• Liver problems – Indicate whether the client’s liver condition is/was cirrhosis or hepatitis. Cirrhosis is 

scarring of the liver and poor liver function. It is the final phase of chronic liver disease. Hepatitis is 

swelling and inflammation of the liver. It is not a specific pathogenic type of condition, but is often used 

to refer to a viral infection of the liver. There are 5 types of hepatitis (A, B, C, D, E); each type is caused 

by a different hepatitis virus. Liver problems include a wide range of diseases and conditions that can 

affect your liver. Your liver is an organ about the size of a football that sits just under your rib cage on the 

right side of your abdomen. Without the liver you cannot digest food, absorb nutrients, get rid of toxic 

substances from your body, or even stay alive. Some symptoms of liver problems are: appearance of 

yellowish skin and eyes, abdominal pain and swelling, dark urine color, pale stool color, chronic fatigue, 

and/or itchy skin that will not go away.

• Lung problems – Indicate whether the client’s lung problem is/was Asthma, Emphysema, Pneumonia or 

Chronic Obstructive Pulmonary Disease (COPD), or some other lung problem. Lung diseases are some of 

the most common medical conditions worldwide. Chronic bronchitis and Emphysema are the most 

common conditions that make up COPD. However, COPD refers to an entire group of other lung 

diseases that cause damage to your lungs and make it increasingly difficult to breathe. Pneumonia is a 

breathing (respiratory) condition in which there is an infection of the lung. Other lung fluid problems 

could be pleural effusion, pulmonary edema, bronchitis, etc. Indicate the recentcy of any pneumonia 

episode, and the type of COPD or asthma the client has/had in the “Notes & Summary” section below. 

(For example: allergic, exercise-induced, nighttime, cough-variant, or occupational) 

• Lupus – Is a chronic inflammatory disease that occurs when the body’s immune system attacks its own 

tissues and organs. Inflammation caused by lupus can affect many different body systems--including 

your joints, skin, kidneys, blood cells, brain, heart, and lungs. 

• Multiple Sclerosis – Is a potentially debilitating disease in which the body’s immune system eats away at 

the protective myelin sheath that covers your nerves. Damage to myelin causes interference in the 

communication between your brain, spinal cord, and other areas of your body. This condition may 

result in deterioration of the nerves themselves, a process that’s not reversible. 

• Muscular Dystrophy – Is a group of genetic diseases in which muscle fibers are unusually susceptible to 

damage. These damaged muscles become progressively weaker. Most people who have muscular 

dystrophy will eventually need to use a wheelchair. There are many different kinds of muscular 

dystrophy. Symptoms of the most common variety begin in childhood, mostly in boys. Other types of 

muscular dystrophy don’t surface until adulthood.

• Osteoporosis – Is the thinning of bone tissue and loss of bone density over time and is a major risk for 

women, and complicates falls, injuries, and the risk for broken bones.

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• Parkinson’s disease – Is a degenerative disorder of the central nervous system, marked by involuntary 

twitches, shakes and writhing movements.

• Paralysis – Indicate whether the client’s paralysis is/was: full, partial, or local (and if local, the site of the 

paralysis). Local paralysis is a loss of motor control that is confined to a single muscle, muscle group, or 

part of the body. For example: left arm, right side, left side, etc. Paralysis is the loss of muscle function in 

part of the body. It can be complete (all sensation and function is cut off from affected part of the 

body) or partial (some movement or sensation remains in the affected muscles or muscle group). It can 

occur on one or both sides. Paralysis of the lower half of the body, including both legs, is called 

paraplegia. Paralysis of the arms and legs is called quadriplegia. Most paralysis is due to strokes or 

injuries, such as spinal cord injury or a broken neck.

• Seizure disorder – Indicate the type and frequency of the client’s seizure disorder. For example, type:

grand-mal, absence, myoclonic, clonic, tonic, atonic, etc. The frequency could be daily, monthly, 

several times a day, etc. Seizures are a symptom of abnormal electrical activity in the brain, and have 

many causes, including medicines, high fevers, head injuries, and some diseases.

• Shingles – Also referred to as herpes zoster, is a painful, blistering skin rash caused by the same virus that 

causes chickenpox (varicella-zoster virus). Shingles may develop in any age group, but you are more 

likely to develop the condition if: you are older than 60, you had chickenpox before age one, your 

immune system is weakened by medications, or some diseases. 

• Stroke/CVA – CVA refers to cerebrovascular accident. There are ischemic strokes, hemorrhagic strokes, 

and transient ischemic attacks (TIAs), which are also called mini-strokes. A stroke happens when blood 

flow to a part of the brain stops. A stroke is sometimes called a “brain attack.”

• Syphilis – A bacterial sexually-transmitted disease (STD), characterized by three stages. The first is the 

appearance of a chancre sore at the site of infection (usually the mouth or genital area). The second is 

the development of more generalized mucous membrane lesions, skin rashes on one or more areas of 

the body, may also include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, 

weight loss, muscle aches, and fatigue. The third and final stage (if left untreated) is called the latent 

phase. Without treatment, the infected person will continue to have syphilis even though there are no 

signs or symptoms; infection remains in the body. This latent stage can last for years. The late stages of 

syphilis can develop in about 15 percent of people who have not been treated for syphilis and can 

appear 10–20 years after infection was first acquired. In the late stages of syphilis, the disease may 

subsequently damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, 

bones, and joints. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle 

movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious 

enough to cause death. 

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• Thyroid problems/Graves/Myxedema – Indicate whether the client’s thyroid problems are/were: hyper 

or hypo. Hyper is when there is too much of the thyroid hormone (Graves disease); hypo is insufficient 

thyroid hormone (Myxedema).

• Tumor(s) – Indicate the site of the client’s tumor(s). For example: brain, breast, colon, lung, prostate, 

cervix, ovary, etc. A tumor is an abnormal growth of body tissue. A tumor can be cancerous 

(malignant) or noncancerous (benign).

• Ulcer(s) – Indicate the site of the client’s ulcer(s). For example: throat, tongue, stomach, digestive tract, 

foot, etc. An ulcer is a lesion that is eroding away the skin or mucous membrane.

• Urinary Tract Infection (UTI) – An infection that involves any of the organs or structures of the urinary 

tract, including the kidneys, ureters, bladder, and urethra. Some of the common symptoms of a urinary 

tract infection are burning or pain in the lower abdomen (that is, below the stomach), fever, burning 

during urination, or an increase in the frequency of urination. UTIs are the most common type of 

healthcare-associated infection (HAI) and are most often caused by the placement or presence of a 

catheter in the urinary tract. 

• Other – Indicate any other health conditions that a doctor has stated the client has/had.

Frequency	of	Current	Therapies	Table

Items in the second half of the health conditions and therapies section identify the frequency of current 

therapies and specialty care the client may be receiving. The current therapies and specialty care that a 

client is receiving have a profound effect on an individual’s health status, self-image, dignity, quality of life, 

and rigor of their daily routine. Evaluation of the intensity of these treatments is important to ensure 

continued appropriateness of the plan of care.

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75. Current Therapies or Specialty Care: Ask the client whether s/he is currently receiving any of the 

therapies or specialty care listed on the form (a-q). If not, mark the box in the first column, “N/A or 

None.” If so, ask the frequency of this therapy or care, and indicate it by marking the appropriate box.

The possible responses are “Monthly,” “Weekly,” “Several times a week,” “Daily,” or “Several times a 

day.” 

a. Bladder/bowel treatment – For example: dietary change, exercise program, medication, surgery, 

medical devices, behavioral techniques, electrical stimulation, etc.

b. Catheter – Indicate the type. In medicine, a catheter is a tube that can be inserted into a body cavity, 

duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical 

instruments. Placement of a catheter may allow, for example: drainage of urine from the urinary 

bladder (e.g., indwelling catheter, condom catheter, intermittent catheter, Foley catheter, suprapubic 

catheter, etc.); administration of IV fluids, medication, or nutrition (peripheral venous catheter); 

administration of oxygen and other breathing gases into the lungs (tracheal tube); subcutaneous 

administration of insulin or other medications (infusion set and insulin pump).

c. Dialysis – When your kidneys fail, you need treatment to replace the work your kidneys used to do.

Unless you have a kidney transplant, you will need a treatment called dialysis. There are two main types 

of dialysis: hemodialysis and peritoneal dialysis. Both types filter the blood to rid the body of harmful 

wastes, extra salt, and water. Hemodialysis does that with a machine. Peritoneal dialysis uses the lining 

of the abdomen, called the peritoneal membrane, to filter the blood.

d. Insulin assistance – For example: someone other than the client draws up the insulin or administers it.

e. IV Fluids/IV Medications – Is the infusion of liquid substances or medications directly into the vein.

f. Occupational therapy – Is a health profession where the goal is to help people achieve independence, 

meaning, and satisfaction in all aspects of their lives. The occupational therapist’s goal is to provide the 

client with skills for the job of living – those necessary to function in the community or in the client’s 

chosen environment.

g. Ostomy – Indicate the site. For example: colostomy (large intestine), ileostomy (small intestine), and 

urostomy (small intestine). All have an opening in the abdomen and use some sort of external means to 

collect the contents of the bowel (like a bag, pouch, etc.)

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h. Oxygen – Oxygen is an important chemical element that is colorless, odorless, and tasteless. It has many 

common uses. Obviously, oxygen is important for human respiration. Therefore, oxygen is used for 

people who have trouble breathing due to some medical condition (such as emphysema or 

pneumonia). The nasal cannula is a device used to deliver supplemental oxygen or airflow to a patient 

or person in need of respiratory help. This device consists of a plastic tube which fits behind the ears, 

and a set of two prongs which are placed in the nostrils. The nasal cannula is connected to an oxygen 

tank, a portable oxygen generator, or a wall connection in a hospital. 

i. Physical Therapy – Is a health profession primarily concerned with the correcting of impairments and 

disabilities and the promotion of mobility, functional ability, quality of life, and movement potential 

through examination, evaluation, diagnosis, and physical intervention.

j. Radiation/Chemotherapy – Radiation therapy involves the use of ionizing radiation in an attempt to 

cure or improve the symptoms of cancer. Radiation is often used in conjunction with chemotherapy. 

Chemotherapy is the treatment of cancer with one or more cyctoxic anitneoplastic (chemotherapeutic 

agents) drugs as part of a standardized regimen. Both radiation and chemotherapy act by killing cells 

that divide rapidly.

k. Respiratory Therapy – Is a therapeutic treatment for respiratory diseases and conditions. A respiratory 

therapist is a health care professional who usually provides these treatments and evaluates the patient’s 

response to the treatments.

l. Skilled Nursing – A term that refers to a client’s need for care and treatment that can only be done by a 

licensed nurse, such as complex wound dressings and tube feedings.

m. Speech Therapy – Is the treatment of speech defects and disorders, especially through the use of 

exercises and audio-visual aids that develop new speech habits. 

n. Suctioning – A term that refers to the process of removing foreign matter, such as mucus, fluids, or 

blood, from a person’s upper airway.

o. Tube feeding –A feeding tube is a medical device used to provide nutrition to patients who cannot 

obtain nutrition by swallowing. The state of being fed by a feeding tube is called gavage, enteral 

feeding, or tube feeding. Placement may be temporary for acute conditions or lifelong for chronic 

disabilities. The types of feeding tubes are: Nasogastric (NG-tube), which is passed through the nostril to 

the stomach and is used short term; Gastric (G-tube), which is surgically inserted through a small incision 

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in the abdomen into the stomach and is used long term; Jejunostomy (J-tube), which is surgically 

inserted through the abdomen and into the jejunum (second part of the small intestine).

p. Wound care/Lesion irrigation –There are many types of wounds that can damage the skin including 

abrasions, lacerations, rupture injuries, punctures, and penetrating wounds. Many wounds are superficial 

and require only local first aid including cleansing and dressing. Some wounds are deeper and need 

medical attention to prevent infection and loss of function due to damage to underlying structures like 

bone, muscle, tendon, arteries, and nerves. Wound irrigation is the steady flow of a solution across an 

open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual 

examination. Combined with debridement (medical removal of dead, damaged, or infected tissue), 

irrigation is a critical step in wound healing.

q. Other therapy – Indicate any other type of therapy or specialty care the client is receiving on a regular 

basis. 

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701D InstructionsSection G. Mental Health

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

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Section	G.	Mental	Health

Mental health problems and severe emotional distress are serious and surprisingly common issues in 

elderly and disabled populations. An estimated 15 to 30 percent of U.S. adults aged 65 and over 

experience depressive symptoms on any given day. For example, did you know that older white 

men comprise the highest risk group for suicide, and adults over 65 have suicide rates that are six 

times higher than the national average? Compounding this problem is that these populations may 

underuse mental health services. This occurs for a variety of reasons, including social stigma,

transportation problems, costs, and misconceptions about mental health problems. 

The items in this section address mental health and mood distress, serious conditions that are 

frequently under-diagnosed and undertreated among adults with disabilities and the elderly. Be 

aware that asking about problems with depression or thoughts of suicide will not make a client feel 

depressed or suicidal - but the assessment may be the first time anyone has asked them about these 

feelings; so some clients may be hesitant to report these symptoms. However, if the Assessor/Case 

Manager has developed rapport with the client and approaches questions in a straightforward, 

compassionate manner, most clients will answer these questions honestly. 

You can make a difference! Research suggests that Case Managers using validated tools 

can successfully help clients identify depression symptoms, self-manage these symptoms 

[see Healthy IDEAS http://www.careforelders.org/healthyideas] and provide clients with 

the encouragement they need to seek assistance from a professional when appropriate.

If the assessment process identifies problems, then remember, you are not expected to try to handle 

critical situations alone. Your responsibility as an Assessor/Case Manager is to immediately report any 

potentially serious problems to your supervisor, a primary care physician, emergency care, law 

enforcement, and/or Adult Protective Services, as appropriate.

Assessor/CM: Because the questions in this section relate to the intimate emotional processes of the 

client, information provided by others is less relevant here. So if someone besides the client - such as a 

family member, a caregiver, etc. is providing answers to the questions in the other sections of the 

assessment, and the client is unable to do so for themselves, you should mark the box and skip 

Questions 76 through 80. 

76. Satisfaction with Quality of Life: Mark the appropriate box (“Very satisfied,” “Satisfied,” “Neither 

satisfied nor dissatisfied,” “Dissatisfied,” or “Very dissatisfied”) to indicate how satisfied the client is with 

her/his overall quality of life. This question opens the conversation for discussing what might be 

preventing the client from being more satisfied with her/his life at present.

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77. Comparison to Prior Year: Mark the appropriate box (“Much better,” “Better,” “About the 

same,” “Worse,” or “Much worse”) to indicate how the client feels about the way things are now 

compared to how s/he was doing this time last year. 

78. Frequency of Depression Symptoms in two week period: This table can be used to identify the 

presence and frequency of each of the nine symptoms of depression listed in items a. through i. The 

possible responses for the frequency of occurrence in each symptom are: “Not at all,” “Several days,” 

“More than half the days,” or “Nearly every day.” 

Thoughts of suicide or self-injury are potentially serious and should be reported 

immediately to a supervisor, primary care physician, emergency care, law 

enforcement, and/or Adult Protective Services, as appropriate.

Assessor/CM: If the client answered “more than half the days” or “nearly every day” to at least one 

item in Question 78, then you will follow up by asking Question 79. If they experienced any of those 

symptoms at a lower rate of frequency, you can skip Question 79 and move on to Question 80. 

79. Severity of Problems: The intent of this question is to determine how any problems identified 

have impacted the client’s quality of life and ability to carry out their daily activities. Indicate the 

client’s response by marking the appropriate box (“Not difficult at all,” “Somewhat difficult,” “Very 

difficult,” or “Extremely difficult”). 

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The PHQ-9, from which these questions are adapted, is a multipurpose instrument for 

screening, monitoring, and measuring the severity of depression. These questions can be 

asked by a lay-person or self-administered over time to evaluate improvement or 

worsening of depression symptoms. To be used for diagnostic purposes or for evaluating 

response to treatment, the responses must be reviewed and scored by a clinician. 

Referral to a Mental Health Professional

The Assessor/Case Manager may need to make a mental health referral. The purpose of a mental 

health referral is to get a professional assessment of a client’s mental health needs and determine if

mental health services are needed. If a client is having emotional problems with ongoing depressive 

symptoms that cause significant personal discomfort or interfere with daily activities, has ongoing 

anxiety and sleep difficulties, or is agitated or angry most of the time (but does not pose a threat to 

others), s/he should be considered for a non-emergency mental health referral. 

Some research suggests that adults with disabilities and older adults are more likely to 

make use of a mental health referral if they are encouraged to try the service by 

someone they trust or respect. Your client may need your encouragement and 

reassurance that mental health services have helped many others. For clients who are 

reluctant to see a mental health professional, encourage them to at least discuss their 

symptoms with their primary care physician and advise them that primary care 

physicians can often help with these symptoms.

Generally, the Assessor/Case Manager should use her/his professional judgment in making a referral 

based upon her/his observation and all information provided. However, if a client has acted out in a 

manner that is dangerous to themselves or others, or if they expressed thoughts of suicide to you or a 

caregiver, consult with your supervisor about whether they should be referred for emergency mental 

health intervention.

80. Currently Working with a Professional: Indicate whether the client is currently working with a 

professional to help with the issues listed in Question 79 (“No” or “Yes”). If the client is already working 

with a professional (“Yes”), skip to Question 81. If not, mark (“No”), and follow up by asking question a.

If the response to a. is “Yes,” you can skip b. If the client does not plan to contact a professional and 

the response to a. is “No,” then follow up by asking if they would be more comfortable discussing the 

problems they are experiencing with someone else (question b). 

a. Plan to discuss these issues with a professional? Indicate the client’s response by marking the 

appropriate box (“No” or “Yes”). If the client does not have plans to discuss mental health issues 

with a professional (“No”), ask question b. 

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b. Talk about any of these issues with anyone else? Indicate the client’s response by marking the 

appropriate box (“No” or “Yes”). “Anyone else” refers to another person, such as a family member, 

friend, clergy, neighbor, etc.

Make sure that you do not “dead-end” a conversation after a client tells you they are in 

distress. You are not expected to counsel a client, but when you identify they are having 

problems, you should confirm they are receiving help elsewhere or make every effort to 

connect them with an appropriate resource.

81. Diagnosis of Mental Condition: Indicate whether the client has been diagnosed with a mental 

condition or psychiatric disorder by a health professional (“No” or “Yes”). If the client has not been 

formally diagnosed, mark “No” and skip to Question 82. If the client has been diagnosed, mark “Yes,” 

and list the conditions in the space provided. 

Although the focus here is collecting information about mental conditions that have been 

diagnosed by a professional, some clients may reveal that they are experiencing distress 

that has not been formally identified. You are encouraged to note these statements in 

notes, and include consideration for these issues in the referral or care planning process.

82. Problem Behaviors: Indicate if you noticed problem behaviors or if any recurring problems have

been reported to you by the caregiver, in-home worker, family, or staff, and note the frequency of 

occurrence for these behaviors in the last month (“Once,” “Several days,” “More than half the days,” 

or “Nearly every day”). Remember that potentially serious problems should be reported immediately to 

your supervisor, the client’s primary care physician, emergency care, law enforcement, and/or Adult 

Protective Services, as appropriate. If no problem behaviors are reported, check “not at all.”

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83. Need for supervision: Indicate “Yes” or “No” if the client needs to be supervised for any reason.

If you indicate “Yes” that supervision is required, detail the reason, intensity level, and whether the 

amount of supervision they are receiving is sufficient and appropriate in the “Notes & Summary” 

section. 

Be aware that clients that require high intensity or constant supervision can be very 

difficult for a single caregiver to properly attend to, and some research suggests that 

clients with high supervision needs are at elevated risk for abuse, neglect, caregiver 

burnout, and institutionalization.

Consider these and other resources that may be available in your area if you have a client with 

cognitive, mental, or behavioral health issues:

Florida Abuse Hotline Information System (Florida Protective Services System) for cases in 

which abuse, neglect, or exploitation is suspected (1-800-96 ABUSE or 1-800-962-2873). 

Alzheimer’s Disease Initiative program or local mental health provider. These are typically for 

non-emergency situations when services and further evaluation are necessary. However, 

mental health providers can also help in an emergency. 

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701D InstructionsSection H. Residential Living Environment 

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

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Section	H.	Residential	Living	Environment

Home safety is an important area of opportunity for injury prevention. For this reason, the items in this 

section have been included to evaluate the client’s physical environment for minimum safety and

accessibility requirements. To complete this section, you will need to combine observation, direct 

questioning, and professional judgment. 

Many older persons and individuals with disabilities or chronic illnesses are vulnerable to serious 

injuries from falls and home accidents. Impairments in the senses of sight and touch, as well as

physical disabilities, may limit client perception or movement, and some memory and cognitive 

impairments may slow judgment and reaction time. As a result, many clients are more prone than 

the general public to falls and accidents. In fact, home accidents are a major source of injuries, and 

falls are the number one cause of injury to persons 65 years of age and older in Florida. Sadly, many 

of these injuries can be seriously debilitating or fatal. Even a minor fall can result in a broken bone, 

which can become an injury that limits one’s independence. 

Over 60 percent of all elder falls occur inside the home. So precautions, adjustments, and 

modifications to residential safety hazards could greatly reduce the threat of injury and greater 

impairment. It may help you to keep this section of the assessment in mind during your entire visit. 

When you notice issues, you will want to revisit them so you can provide specifics about the 

problems and areas in need of attention. In discussions with the client, you will want to indicate the 

immediacy of the need based on the level of risk. On the form, be sure to indicate both your 

concerns and any that the client may have articulated, as well as any ideas for how to fix the issues 

you both identify. These concerns will need attention in the care plan and will be used to determine 

appropriate referrals. Pay particular attention to safety or accessibility problems for the client as 

these may greatly affect the client’s ability to evacuate in an emergency. The HCE Safety and 

Accessibility Worksheet may be used to help with this assessment (See Attachment B). 

84. Potential Safety or Accessibility Problems: Mark the items on the form that are problematic for 

the client. Write in any other issues that do not appear on the assessment form. These items will be 

checked based on the direct observation of the Assessor/Case Manager or as reported by an 

informant. 

If information about the client’s residence is reported to you, without your direct 

observation, check the indicated box and then mark all applicable issues in the 

sections that follow (Question 84 a-h). This box will be checked when the 

Assessor/Case Manager is not assessing the client in her/his home. For example, 

the client may be assessed in a nursing facility but is planning to return to her/his

home setting and information regarding the client’s residence is reported to the 

Assessor/Case Manager by an informant.

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Check all that apply:

a. Exterior issue(s): Note any potential safety or accessibility issues with the road, driveway, yard, 

doors, windows, or roof of the home, keeping in mind the importance of a clear line of site and 

pathway for entering and exiting the residence. The residence should have secure surfaces (such as 

railings near exterior stairs); proper lighting; ability to see outside (so as not to have to open the door to 

greet someone); door locks that work properly and can be opened by those who visit the residence; 

a doorbell that can be heard in all areas of the residence; frequently traveled outside surfaces (i.e., to 

and from the mailbox, garbage cans, pet walking areas) that are free from trip hazards; wheelchair 

and walker accessibility as needed; easy access to the garage with proper lighting and working doors 

(automatic garage doors should be checked for functionality and the client should know how to exit 

in case of power failure).

b. Interior issue(s): Note any potential safety or accessibility issues including ramps and stairs or 

issues with the flooring, walls, ceiling, or lighting, keeping in mind that the client should be able to 

move around the area without having to make special accommodation to enter or exit a room.

Spaces in the residence should generally allow 42” or greater in all pathway areas of the home; 

extension, phone, or appliance cords should not be present in ambulation pathways; entrances to 

rooms should provide lighting access; windows should be easy to open and close; blinds and curtains 

should easily allow the client to open and close them to reduce glare (glare negatively impacts visual 

capability in the elderly and increases the likelihood of a fall); carpeting should be properly secured or 

removed; all rooms should be adequately lit; flooring height differences should be noted and 

changes made if a trip hazard is present; floors should be clean and dry; pet food, water, pet sleeping 

areas, and toys should not be walking obstacles.

In residences in which stairs are present: stairway surfaces should be free of objects; check for loose 

steps and ensure that each step is visible in all lighting situations; if steps are unequal in height, depth, 

or width, make sure the resident is aware of the differences; light switches should be available at the 

top and bottom of the stairs; make sure all carpeting on stair surfaces is adequately secured and 

install “skid-strips” in areas where the surface presents a slip hazard; check the security of rails and, if 

possible, install a rail on both sides of the stairway.

Refer back to the General Health and Function Section to the item regarding the client’s 

ability to climb a few stair steps. If they are not able to use steps, but have steps within or 

leading from the home, they may be severely restricted from freely moving in the home. 

c. Restroom issue(s): Note any potential safety or accessibility issues in the restroom with the door, 

handrails, tub, shower, or toilet. Keep in mind that walker and wheelchair access may not be possible 

in some Florida residences and, in other instances, turning the walker and ambulating “sideways” may 

allow entrance/exit from the bathroom. In the restroom, all rugs must be secured to the floor despite 

the dangers of water on the floor; toilet seat height must be appropriate to meet elder needs; grab 

bars should be located in the shower, tub, and near the toilet area; water temperature should not 

present a burn hazard; shower benches are very important to those with balance problems; “anti-slip 

strips” should be installed in the tub and shower; nightlights should be installed; all “most frequently 

used” personal supplies should be easy to reach; installation of a hand-held shower wand should be 

considered; and, if opportunities are available, a phone in the bathroom is useful. 

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d. Utility issue(s): Note any potential safety issues with the plumbing, water, electric, or gas. For 

example, is there an unofficial electrical hookup to the home; does the home have running water 

and indoor plumbing; are there space heaters or generators being used, etc.? 

e. Furniture issue(s): Note any potential safety or accessibility issues with the furniture in the home, 

such as chairs, couches, beds, or tables. Furniture that presents trip hazards should be moved out of 

common pathways. Chairs that require “low seating” should be removed, and use of wheeled 

furniture or furniture that is broken should be avoided. Any furniture that is used for stability (i.e., 

frequently grasped while ambulating through a room) should be secured to the floor – in particular, 

check furniture that is on wood or terrazzo flooring, and ensure chairs that are frequently used have 

secure arm rails. Bed height should allow the client to get easily in and out with minimal effort.

f. Telephone issue(s): Note any potential safety or accessibility issues with telephone service in the 

residence, including lack of a phone, broken phone(s), or no/disconnected service. Whenever 

possible, it is advisable to have phone availability in all rooms of the home. Note: A referral for 

emergency alert response may be needed if the client does not have phone availability in all rooms 

of the home.

g. Temperature issue(s): Note any potential safety issues with heat, air conditioning, or smoke 

detectors in the residence. A clear path to thermostats should be present, and all smoke detectors 

should be in proper working order. Note: Most fire departments will come to a residence and check 

smoke detectors, as well as provide new ones.

h. Unsanitary condition(s): Note any potential issues with unsanitary conditions including odors, 

insects, rodents, cluttered floors or pathways, or accumulating items or garbage. Be sure to note any 

other unsanitary condition not listed on the form in the space provided (“Other hazards”).

85. Pet in Home or Yard: Indicate the client’s response to this question by marking the appropriate 

box (“No” or “Yes”). If the client does not have a pet in the home or yard (“No”), skip questions a. 

and b. If a pet is present (“Yes”), indicate a. the type and size of the pet, and b. any comments or 

concerns related to the pet. This information will be useful to the Assessor/Case Manager and others 

visiting the home for the safety of staff and the pet. For example, the client may ask the Assessor/Case 

Manager to call before arriving so s/he can secure the dog or put the cat in a different room. 

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86. Level of Risk in Living Environment: The items identified above are to be used as a guide to assist 

the Assessor/Case Manager in evaluating the level of risk in the client’s living environment. 

The Assessor/Case Manager is to use her/his professional judgment, not personal 

choice, in determining the issues in the client’s home environment. For example, 

the floors in the client’s home may not be as clean as you think they should be or 

there may be dirty dishes in the sink, but if they do not negatively affect the 

client’s safety or accessibility, they would not be checked or considered in 

determining overall level of risk. 

Determine the environmental assessment risk level based on the description that best describes the 

client’s physical environment:

“No/low apparent risk from current living conditions” - The client’s residential living environment 

appears to be safe and accessible.

“Minor risk” – One or more aspects are substandard and should be addressed in the following year to 

avoid potential injury.

“Moderate risk” – Major aspects are substandard and must be addressed in the next few months to 

remain in home safely.

“High risk” – Serious hazards are present. The client must change dwellings or immediate corrective 

action must be taken to correct the issues noted.

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701D InstructionsSection I. Nutrition

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

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Section	I.	Nutrition

The items in this section evaluate the client’s weight, diet, fluid intake, and overall nutritional health.

This section is included in the comprehensive assessment because the warning signs of poor 

nutritional health are often overlooked by healthcare providers. So, a standard set of measures was

established as a federal screening under the Older Americans Act, called the “DETERMINE” 

Checklist, to identify common risk factors and warning signs of poor nutritional health. Although 

these factors were initially developed for identifying risks in an older population, they are quite 

relevant to younger adults with disabilities and chronic illnesses, too. 

“D:” Disease – Any disease, illness, or chronic condition that causes someone to change the way 

they eat, or makes it hard for them to eat, puts their nutritional health at risk. Four out of five adults 

have chronic diseases that are affected by diet. Additionally, cognitive and emotional problems 

play a role in nutrition. For example confusion or memory loss is estimated to affect at least one out 

of five older adults, which can make it hard for them to remember what, when, or if they have 

eaten. And feeling sad or depressed, which happens to about one in eight older adults, can cause 

big changes in appetite, digestion, energy level, weight, and well-being.

“E:” Eating Poorly – Eating too little and eating too much both lead to poor health. Eating the same 

foods day after day, or not eating fruit, vegetables, and milk products daily will also cause poor 

nutritional health. One in five adults skips meals daily. Only 13 percent of adults eat the minimum 

amount of fruits and vegetables needed. 

“T:” Tooth Loss/Mouth Pain – A healthy mouth, teeth, and gums are needed to eat. Missing, loose, or 

rotten teeth or dentures which do not fit well may cause mouth sores and make it hard to eat.

“E:” Economic Hardship – As many as 40 percent of older Americans have incomes of less than 

$6,000 per year. Having less – or choosing to spend less – than $25 to $30 per week on food makes it 

very hard to get the foods needed to stay healthy.

“R:” Reduced Social Contact – One-third of all older people live alone. Being with people daily has a 

positive effect on morale, well-being, and eating.

“M:” Multiple Medicines – Many older Americans must take medicines for health problems. Almost 

one half of older Americans take multiple medicines daily. Growing old may change the way 

people respond to medication. The more medicines a person takes, the greater the chance for side 

effects such as increased or decreased appetite, change in taste, constipation, weakness, 

drowsiness, diarrhea, nausea, and others. Vitamins or minerals, when taken in large doses, act like 

drugs and can cause harm. 

“I:” Involuntary Weight Loss/Gain – Losing or gaining weight, when one is not trying to do so, is an 

important warning sign that must not be ignored. Being overweight or underweight also increases 

the chances of poor health.

“N:” Needs Assistance in Self Care – Although most older people are able to eat, one of every five 

has trouble walking, shopping, buying, and cooking food, especially as they get older.

“E:” Elder Years above Age 80 – Most older people lead full and productive lives. But, as age 

increases, the risk of frailty and health problems also increases. 

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87. Two meals a Day: Indicate the client’s response to this question by marking the appropriate box

(“No” or “Yes”). It is important to determine how many meals a client eats a day, as nutrition is vitally 

important to good health. If the client states s/he does not eat at least two meals a day, the 

Assessor/Case Manager needs to ask the client why. Be sure to include this information in the “Notes & 

Summary” section. 

88. Types of Food: Ask the client to describe what types of food s/he eats in a typical day for a. 

breakfast, b. lunch, c. dinner, and d. snacks. 

When asking what the client eats each day, you might want to walk the client through 

the previous day, from the time s/he woke up in the morning until s/he went to bed at 

night. Remember that weekends could be different from the rest of the week. Try to 

determine whether the diet is balanced, how much food is consumed, and when the 

food is normally eaten. Record the responses in the appropriate text boxes. 

89. Eat Alone: Ask the client whether s/he eats alone most of the time and mark the appropriate 

response (“No” or “Yes”). This question is very important, as it could indicate social isolation. If the 

response is “Yes,” the Assessor/Case Manager needs to discuss the reasons with the client. Be sure to 

include this information in the “Notes & Summary” section.

90. Liquid Intake: First, ask the client how many cups of water, juice, or other liquid s/he drinks daily.

If the response is more than eight, skip questions a. and b. If the response is less than eight, ask 

question a. :

a. Limits Fluids: Ask the client if s/he ever limits the amount of fluids s/he drinks and mark the 

appropriate response (“No” or “Yes”). If the response is negative (“No”), skip question b. If the 

client does limit fluids (“Yes”), then ask b. 

b. Reason for Limiting Fluids: Ask the client why and when s/he limits fluids and record the 

response in the text box. Sometimes clients limit their intake due to incontinence issues, but can 

cause other health problems by doing so. For example, a client may not drink any fluids several 

hours prior to going to bed to avoid accidents, and notice they start feeling dehydrated in the 

warmer months, or have had frequent urinary tract infections as a result. 

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91. Fruits/Vegetable Intake: Read the description of serving size and then ask the client how many 

servings of fruits and vegetables s/he eats every day, on average. Record the numerical response in 

the box. 

92. Dairy Intake: Read the description of serving size and then ask the client how many servings of 

dairy products s/he has every day, on average. Record the numerical response in the box. 

93. Height/Weight Estimate: Current height and weight are also related to nutrition. The client may 

not know her/his current height or weight, or may not care to divulge the information, but note the 

information you are able to obtain from the client. Record weight in pounds and height in feet and 

inches. 

94. Gained/Lost Weight: Ask the client if s/he has lost or gained weight in the last few months and 

mark the appropriate response (“Unsure,” “No,” or “Yes”). Note: “The last few months” is used instead 

of a specific time frame to allow for ambiguity of client recall. The Assessor/Case Manager may need 

to prompt the client with “in a time frame of the last 3 to 6 months.” If the response is “Unsure” or “No,” 

skip questions a. and b. If the response is “Yes,” ask questions a. and b.:

a. Amount of Weight: Ask how much weight the client has lost or gained in the last few months and 

mark the appropriate response (“Less than 5 pounds,” 5 to 10 pounds,” or “10 pounds or more”). 

b. Purposeful Change: Ask the client whether the weight gain/loss was on purpose – for example, 

whether they were trying to lose or gain weight, and record the response (“No” or “Yes”). An 

unintended weight change could indicate a health problem, and the client’s doctor should be 

notified. 

95. Special Diet: Ask the client whether s/he is on a special diet(s) for medical reasons and record 

the appropriate response (“No” or “Yes”). If the response is “No,” do not check any of the diet types 

and skip questions a. and b. If the response is “Yes,” indicate the type of special diet(s) by marking the 

appropriate boxes (“Calorie supplement,” “Low fat/cholesterol,” “Low salt/sodium,” “Low 

sugar/carb,” or “Other”). Be sure to note any “other” type of diet that is not listed on the form in the 

space provided in the “Notes & Summary” section. 

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a. Length on diet: If a client answers “Yes” to having a special diet prescribed for medical 

reasons, indicate how long the client has been on this diet.

b. Reason for diet: If a client answers “Yes” to having a special diet prescribed for medical 

reasons, indicate the reason for the diet. 

Be aware that multiple dietary restrictions indicate that the client is at greater nutritional risk. 

If a client is receiving home-delivered meals, a special diet may be requested from some

providers. 

96. Difficulty Chewing/Swallowing: Ask the client if s/he has any problems that make it hard to 

chew or swallow and mark the appropriate response (“No” or “Yes”). If the response is “No,” do not 

check any of the problem boxes. If “Yes,” indicate what these problems are by checking the 

appropriate boxes (“Mouth/tooth/dentures,” “Pain or difficulty swallowing,” “Taste,” “Nausea,” “Saliva 

production,” or “Other”). Be sure to note any “other” problem that is not listed on the form in the 

space provided. More than one problem can be checked; the intent is to capture any and all 

problems affecting the client’s ability to chew or swallow. 

97. Working Appliances: Indicate what working appliances, if any, the client has for 

storing/preparing food (“Other,” “Refrigerator,” “Microwave,” “Toaster/Oven,” “Stove,” or “None”). Be 

sure to note any “other” source that is not listed on the form in the space provided. More than one 

item can be checked; the intent is to capture all sources the client has for storing and preparing food.

If the response is “None,” the Assessor/Case Manager needs to ask the client how they store and 

prepare food. Be sure to include this and any other relevant information about their ability to store 

and prepare food in the “Notes & Summary” section.

The Nutrition Score will be calculated by CIRTS and will appear on the turnaround 

document. The range of risk for malnutrition is Low = 0 to 2, Medium = 3 to 5, and a 

High = 5.5 to a maximum score of 21. Clients with nutrition scores that are 5.5 or higher

show a high risk for malnutrition. It is strongly suggested that these clients be referred 

for nutrition counseling. 

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701D InstructionsSection J. Medications & Substance Use

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

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Section	J.	Medications	&	Substance	Use

With the progression of the diseases, conditions and ailments that many clients manage, their use of 

different medicines may increase and become more complex to manage properly. These 

medicines are prescribed to ease, control, or cure ailments and are usually safe when used 

correctly. However, the combination of increased numbers of medications being used at once, 

paired with the normal bodily changes that occur over the course of some diseases, can increase 

the chance of unwanted and harmful drug interactions. Elders and disabled adults may be at 

increased risk from medicines for various reasons, such as: 

As the body ages, the liver becomes less efficient at breaking down medicines and the

kidneys become less efficient at excreting them, which means that normal adult doses of 

certain medicines may cause more side effects in an older client; 

The brain and nervous system become more sensitive to certain medicines with some 

conditions and may make some clients more susceptible to the side effects of opioid 

painkillers such as morphine and sleeping tablets such as diazepam; 

Sensory disabilities, such as visual impairment, are linked with improper administration of 

medication and can cause problems with differentiating medications from one another, 

reading small print labels, and understanding all the information supplied with medicines. 

Individual medications may pose greater risk for some groups, and the opportunities for misuse in 

multiple medications are compounded. According to one study of adults taking five or more 

medications, 35 percent experienced an adverse effect from at least one prescribed drug, 63 

percent of these events required physician intervention, 10 percent required an ER visit, and 11 

percent were hospitalized. Non-adherence to medication regimens is also a major cause of nursing 

facility placement of older adults. In the same study, 28 percent of all hospitalizations among older 

adults were found to be drug-related, 11 percent of which were for improper prescription 

adherence. These findings and others suggest that more effort is needed in educating clients about 

the risks and precautions in managing medications. There are four basic tips that can aid with 

medication awareness, medication knowledge, and communication regarding medications: 

1. Help clients make a list of all medications they take, why and when they take it, the dose, 

and possible side effects or special instructions; 

2. Suggest that the client use only one pharmacy and involve a pharmacist in medication 

management; 

3. Suggest that the client keep their medications organized with a pill minder or other assistive 

system; and

4. Recommend that the client update the medication list and review with the primary care 

physician as often as needed. 

The more a client knows about the medicines they take and the more they talk with their healthcare 

professionals, the easier it is to avoid potential medication problems. This section collects medication 

use information and will enable you to have the conversation with the client about these 

medications to determine if they are managing their medications properly.

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Medications,	Prescribers,	Compliance	and	Management

98. Three or More Medications Daily: Ask the client if s/he takes three or more prescribed or overthe-counter medications daily and mark the appropriate response (“No” or “Yes”). Be aware that 

taking three or more medications daily (including prescription, non-prescription, herbal or dietary 

supplements) puts the client at a higher risk for medication management and interaction problems.

“Polypharmacy” is the term used to describe when someone takes multiple prescriptions 

and over-the-counter medicines each day. Although this may often be necessary to 

manage multiple conditions, clients and caregivers should be especially careful when 

there are multiple medications to manage to practice good medication management 

habits to prevent clients from taking them incorrectly. 

99. Record of Medications: Record any medications used by the client. These will be prescription 

and non-prescription (over–the-counter drugs, sleep aids, herbal remedies, supplements, and 

vitamins). For each, indicate the medication name; the prescribed dose of the medication; the 

prescribed frequency of the medication dosage; whether or not the medication is taken as 

prescribed; the administration method; and, when applicable, the prescriber’s name.

You should check the original containers for information, keeping in mind that some 

may be in the medicine cabinet, nightstand, refrigerator, etc. If there are more 

medications to record, use the “Notes & Summary” section or a blank sheet of 

paper to write the information. If you have a printed list of medications managed by 

a facility, attach the sheet. 

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100. Reason for Non-Compliance: If the client indicates that s/he is taking a medication improperly 

or is not taking any given medication as prescribed in Question 99, the Assessor/Case Manger should 

ask them why they are taking the medication differently than prescribed. Ask the client about each 

medication and record the medication and reason for non-compliance in the space provided.

Consider the following possible compliance-related issues:

Cannot afford: May clients on fixed incomes cannot afford to maintain their medications if 

they increase in price or if they have other expenses come up. As a result, some clients try to 

“stretch” their medication by doing things like cutting pills in half, taking it only once a day or 

otherwise less often than as prescribed, letting a few weeks pass without refilling a prescription, 

or other ways that may cause the client to receive the incorrect dosage or frequency.

Confused: Confusion can come from many sources or a combination of sources and may be 

the cause or the symptom of misuse of medications. The client may suffer from disorientation

from the side effects of sedatives or sleeping pills, urinary tract infection, dehydration, sleep 

disorder, emotional problems, dementia, vision or hearing loss, illiteracy, or some other reason 

that causes them to not stick to a medication routine, or lack clarity on how to take the 

medications as prescribed. 

Self-Assessment: The client may have decided they feel better and no longer need to take 

the medicine; they may have decided that the effort to take the medication as prescribed is 

too difficult, or the side effects of the medication are not tolerable. Conversely, they may selfdiagnose that they have a problem that they saw advertised on TV, or heard about from a 

friend, and decide to start taking over-the-counter medications they may not need or that 

may interact with others they were already prescribed.

Drug interaction or side-effects: The client may be taking medications that duplicate or 

compete with each other, or have similar side effects. The Assessor/Case Manager should look 

for possible drug interaction if the client reports not feeling well when they take a medication 

or reports stopping some medication because of intense side effects. Also, clients may be at 

greater risk for drug interaction if they get prescriptions from multiple doctors or multiple 

pharmacies. 

Alcohol or controlled substance interaction: Use of alcohol or illegal “recreational” drugs with 

some medications may greatly diminish, enhance, or change their effect on the client and 

her/his conditions. Moreover, the use of these substances may impair the client’s judgment in 

managing their medications, may make the client less likely to go see their physician or be 

honest with them, and may strain the financial resources needed to afford some medications. 

 

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101. Physician Listing: List all of the doctors that the client usually goes to for treatment and 

medications along with his/her phone number, the approximate date of the client’s last visit with the 

doctor, and the reason for that visit. If there are more than 10 physicians of record, use the “Notes & 

Summary” section to write the information on each. Be aware that clients may use multiple doctors as 

drug diversion. This is where they intentionally request prescriptions for the same drug from multiple 

prescribers to avoid suspicion in an attempt to obtain more of the medication.

102. Pharmacies Used: List the pharmacies or drug stores that the client uses in the space provided. 

When clients use more than one pharmacy to fill their prescriptions, there is an increased chance of a 

drug interaction, duplicate therapy, or a possible decrease in compliance. Be aware that clients may 

use multiple pharmacies as drug diversion. This is where they intentionally fill prescriptions for the same 

drug at multiple pharmacies to avoid suspicion in an attempt to obtain more of the medication.

103. Differentiate Medication: Ask the client whether s/he is able to tell the difference between 

her/his pills, including colors, shapes, and print, and mark the appropriate response: 

• “No” - Client cannot tell the difference between the characteristics of the pills they take

• “Yes” – Client can tell the difference between shapes, colors, and print of the pills they take

• “N/A” - Client does not take any medication

“Medication awareness” means the client fully understands what they take, when they take 

it, what it looks like (color, shape, print), and why they take it. Making sure that a client who is 

managing their own medications has full medication awareness can help prevent a great 

deal of harm. 

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104. Medications Managed by Others: Indicate whether the client’s medications are managed by a 

facility or caregiver (“No – client medications are self-managed, not assisted by a facility or 

caregiver,” “Yes – medications are managed by a facility or caregiver,” “N/A – client takes no 

medications to manage”). 

Examples: If the client resides at home and manages to fill, take, and monitor any 

adverse effects of all medications, the response would be “No.” If a client resides in a

nursing facility, where all medications are administered and reviewed by the facility staff, 

then the response would be “Yes.” 

105. Medications Managed Properly: Based on the client’s responses to the medication questions, 

indicate whether you believe the client’s medications are managed properly (“No,” “Yes,” or “N/A”).

• “No” – The client is non-compliant with medications, cannot differentiate medications, and/or 

has no medication awareness (what medications are for, side effects, when and how to take 

them, etc.). The response would also be “No” if a facility or caregiver is not properly following the 

prescribed medication regimen. 

• “Yes” – The client, caregiver, or facility is well aware of all medications and follows the 

medication regimen appropriately.

• “N/A” – The client does not take any medication or the caregiver or facility refused to provide 

the information.

106. Medication Review: Based on the client’s responses to the questions above in Section J, 

indicate whether you believe the client should have a new medication review by a doctor or 

pharmacist (“No,” “Yes,” or “N/A”). 

• “No” – The client does not require a new medication review. The client’s medications are not 

complex and the client is managing all medications appropriately.

• “Yes” – The client requires a new medication review if the medication management is complex, 

or the client is taking many medications of the same type, or the client is inappropriately using 

their medications (often seen due to side effects or expense of some medications). The 

Assessor/Case Manager can recommend the client have all of their medications reviewed by a 

specialist for ways to simplify the regimen, to remove conflicting or redundant medications, or to 

suggest drug substitutions or lower dosages to resolve issues with non-compliance or improve 

medication tolerance. 

• “N/A” – This question does not apply to the client as s/he has no new medication or does not 

take any medication.

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Alcohol,	Tobacco	and	Substance	Use

Although substances like alcohol, tobacco, and illicit drugs can be expensive, dangerous, and 

harmful to overall health; they are commonly used in some areas of the state, in some subpopulations, and in some phases of the lifespan. Younger adults are typically portrayed as the 

consumers and users of alcohol, tobacco, and drugs; however substance use has been shown to 

peak during major life disruptions common with disabled adults and in later life. Events such as 

retirement, relocation, chronic sleeping problems, social isolation or loneliness, disability, chronic 

pain, grief and widowhood all cause major disruptions that many people find hard to work though. 

These major transitions are thought to be some of the main contributory factors among people who 

develop problems with substance use. Despite evidence that there have been significant increases 

in substance use in elders and adults with disabilities, these groups are often overlooked when 

health care providers screen for substance use issues, due to stereotypes and misconceptions. The 

items in this section are for your use in determining the severity of substance use, if it is impairing 

client function, and if referral may be desired or appropriate.

107. Alcohol Use: Ask the client how many days in a typical week s/he drinks alcohol and record the 

response in the appropriate box (“Refused,”“None,” “1 to 2,” “3 to 5,” or “6 to 7”). If the client refuses 

to answer the question (“Refused”) or responds with “None,” skip questions a. and b. If the client drinks 

alcohol on one or more days a week, ask question a. 

a. Number of Drinks: Ask the client how many drinks s/he usually has on the days when s/he has 

some alcohol and mark the appropriate response (“1 to 2,” “3 to 5,” or “6 or more”). If the 

response is “1 to 2,” skip question b. If the client usually has three or more drinks on the days 

when s/he drinks, ask b. 

b. Four or More Drinks: Ask the client about how many times in the past month s/he has had four 

or more drinks in a day and record the response (“None,” “1 to 2,” “3 to 5,” or “6 or more”).

Did you know? One in four older adults drinks too much alcohol. Many health problems 

become worse if a person drinks more than one or two alcoholic beverages per day, and 

with some conditions and medications, any amount of alcohol can be dangerous. 

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108. Tobacco Use: Indicate whether the client has used any form of tobacco in the last six months 

(“No” or “Yes”). This includes use of cigarettes, cigars, chewing tobacco, and snuff. If the response is 

“No,” skip questions a. and b. If the client has used tobacco in the last six months (“Yes”), ask 

questions a. and b.:

a. Type(s) of Tobacco: Indicate all type(s) of tobacco that the client has used in the last six 

months (“Chewing tobacco,” “Cigarettes,” “Cigars,” “Snuff,” “Other”). Note any other type in 

the “Notes & Summary” section.

b. Frequency of Use: Indicate how many times the client uses tobacco each day (“1 to 3,” 

“4 to 10,” or “11 or more”).

109. Drug Use: Indicate whether the client regularly uses drugs other than those required for medical 

reasons (i.e., controlled substances or “street drugs”) (“No” or “Yes”). If the client’s response is 

“Refused” or “No,” skip questions a. and b. If the client regularly uses drugs (“Yes”), record the types of 

drugs used in the space provided and then ask questions a. and b.:

a. Frequency of Use: Indicate how often the client uses drugs (“Rarely,” “Less than twice a 

month,” “Less than once a week,” “Several times a week,” “Daily,” or “Several times a day”).

b. Length of Use: Indicate how long the client has been using drugs at the frequency noted in 

Question 109a. (“Less than a year” or “1 or more years”).

Many people who engage in long-time drug use develop addictions and do damage to 

their bodies such that they do not survive until their senior years. However, in those clients 

who have a history of abusing drugs earlier in life, the use of a combination of substances 

is common. Be aware that as age-related changes take place in the body, and as the 

course of some diseases progress, many life-long users find that their recreational drug 

use is having new effects on their body and mind. With those changes, these substances 

pose new dangers. In particular, the concurrent use of illegal drugs with prescription 

medications can lead to life-threatening interactions. So, if a client is willing to discuss 

their substance use with you, you should make sure that they are aware of any cessation 

counseling services in your area.

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701D InstructionsSection K. Social Resources & 

Section L. Caregiver

Guidance for Completion of the Department of Elder Affairs’ 

701B Comprehensive Assessment

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Section	K.	Social	Resources

The intent of this section is to determine the client’s degree of social isolation. Social isolation can be 

defined as the absence of social interactions, contacts, and relationships with family and friends, 

with neighbors on an individual level, and with “society at large” on a broader level. Social isolation 

is considered a risk factor for developing or worsening some diseases and can also intensify 

negative feelings about health conditions and disabilities. 

110. If needed, is there someone who could help you?: Indicate the client’s response to this question

by marking the appropriate box (“No” or “Yes”). If the client does not have someone else to help 

them if needed (“No”), skip to Question 112. If the client does have another person who could help 

them if they needed anything (“Yes”), ask Question 111.

111. Contact: If the client has someone to help, ask if you have permission to contact this person if 

needed (“No” or “Yes”). If the client does not give permission to contact this person (“No”), skip parts 

a., b., and c. If the client gives permission (“Yes”), enter a. the contact person’s name, b. relationship 

to the client, and c. phone number, including area code, in the spaces provided. If the contact 

person does not have a phone, this may be left blank. 

If the client is uncertain of the spelling of the contact’s name, see if the client has it written 

somewhere. If the client identifies a person by title, try to clarify what is meant. This is a vital care 

planning issue to be discussed with the client.

112. Frequency of Conversations with Others: Indicate the client’s response to this question by 

marking the box that best corresponds to the client’s response (“Once a day,” “2-6 times a week,” 

“Once a week,” “Several times a month,” “Every few months,” “A few times a year,” or “Never”). If the 

client’s response is not covered in the options given, pick the one that is closest to the frequency of 

contact.

113. Frequency of Visits with Others: Indicate the client’s response by marking the box that best 

corresponds to the client’s response (“Once a day,” “2-6 times a week,” “Once a week,” “Several 

times a month,” “Every few months,” “A few times a year,” or “Never”). If the client’s response is not 

covered in the options given, pick the one that is closest to the frequency of visits. 

 

Find out who the client spends time with. Also try to determine if the client would like to do more. 

This could help you establish a need for some kind of companion service.

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114. Frequency of Activities Outside the Home: Indicate the client’s response by marking the box 

that best corresponds to the client’s response (“Once a day,” “2-6 times a week,” “Once a week,” 

“Several times a month,” “Every few months,” “A few times a year,” or “Never”). If the client’s 

response is not covered in the options given, pick the one that is closest to the frequency of activities.

To help the client answer, you may need to prompt them with examples of hobbies or 

activities they may engage in. For example, do they go to a place of worship? Are they 

active in a local bridge group? Do they regularly attend social clubs, charitable 

organizations, or neighborhood association meetings? If they respond that they “Never” 

engage with others outside the home, you may want to ask if there are things they really 

liked doing but believe they cannot do anymore or find out why they stopped. If there are 

things the client can still do, see what help might be needed for them to reconnect and 

engage with others. Sometimes the solution to social isolation is as simple as incontinence 

supplies, a walker, or transportation services, and can have a profound impact on client 

quality of life.

Section	L.	Caregiver

Many clients do not have a person who can be relied upon to provide or arrange for assistance with 

their activities of daily living, also called a primary caregiver. For those who do, this person can be a 

lifeline to vital help and assistance - without which they would be far more vulnerable to 

institutionalization or worse. When a primary caregiver is present, it is important to arrange to 

conduct the last section of the assessment form with them in private, away from the client or other 

family members that may impact their comfort level in providing honest responses to questions. 

Although the intent of this section is to gather information about the client’s caregiver to better 

understand the care being provided to the client, it is also to collect information about the ways 

that caregiving may be adversely impacting the caregiver’s life, and the kinds of stress they are 

managing as a result. Many areas of the state have services in place for caregivers that can help 

prolong their ability to remain in place to help clients; so gathering this information is an important 

part of care planning. Additionally, many caregivers can provide valuable insight if the client has 

cognitive or behavioral issues you need to be aware of. If the client does not have a caregiver, stop 

the assessment here. The Caregiver Section fields will only appear in CIRTS if there is a primary 

caregiver. 

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115. ASSESSOR/CM: HCE Caregiver: Check the box if the client’s caregiver is an HCE Caregiver (has 

met all eligibility requirements and is enrolled in the Home Care for the Elderly program). Leave the 

box blank if the caregiver is not an HCE Caregiver.

116. Caregiver Name: Obtain the caregiver’s full name (first, middle initial, and last) and note it in

the spaces provided. If the caregiver does not have a middle initial, leave the space blank.

117. Caregiver Date of Birth: In the space provided, note the caregiver’s date of birth in a two 

number format for the month (i.e., February would be ‘02’), likewise, use the two number format for 

the day (i.e., the third of the month would be ‘03’) and a four number format for the year (i.e., 2012) 

as indicated by “mm/dd/yyyy” throughout the form. 

118. Caregiver Identification Number: This number is a unique identifier for the caregiver. It is 

comprised of her/his initials (first, middle, last) and her/his date of birth in mm/dd/yy format. In the 

space provided, enter the nine-digit caregiver identification number. 

If the caregiver does not have a middle initial, you would use “X”. For example, if the caregiver’s 

name is Jane Ann Smith and the date of birth is 05/02/1965, you would enter JAS050265 for the 

caregiver identification number. If the caregiver’s name is Jane Smith with no middle initial and 

the same date of birth, you would enter JXS050265 for the caregiver identification number. 

119. Caregiver Sex: Mark the appropriate box to indicate whether the caregiver considers 

themselves to be female or male. 

120. Caregiver Race: Obtain the caregiver’s response and mark the box or boxes, as applicable, to 

indicate the caregiver’s race. Caregivers may provide more than one response. These categories are 

suggested by the federal government for reporting under the Older Americans Act: 

• “White” 

• “Black/African American”

• “Asian” 

• “American Indian/Alaska Native”

• “Native Hawaiian/Pacific Islander”

• “Other” (Any other racial group not coded above)

 

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121. Caregiver Ethnicity: Obtain the caregiver’s response and mark the appropriate box to indicate 

the caregiver’s ethnicity. The only distinct ethnic grouping that must be reported to the federal 

government is “Hispanic/Latino.” NOTE: A person of Hispanic ethnicity may be from any race. 

• “Hispanic/Latino”

• “Other” (Any other ethnicity not coded above): If it is relevant for care planning, use the area in 

“Notes & Summary” to write a brief description of their ethnicity and the accommodations the 

client needs as a result. 

122. Caregiver Primary Language: Mark the appropriate box to indicate the primary language 

spoken by the caregiver. When collected during the screening process, this information may enable 

the agency to send a worker to the home or arrange for someone who will be able to communicate 

most effectively with the caregiver. 

• “English”

• “Spanish”

• “Other” (Any other language not coded above): Write-in a brief description of this “Other” 

language.

123. Caregiver Relationship to Client: Indicate the caregiver’s relationship to the client: 

• “Wife:” The female legal spouse of a client.

• “Husband:” The male legal spouse of a client.

• “Partner:” The person with whom the client is in a relationship, other than a legal spouse. 

• “Parent:” Includes biological or step-parents to the client.

• “Son/In Law:” Includes biological, step-son, and son-in-law to the client.

• “Daughter/In Law:” Includes biological, step-daughter, and daughter-in-law to the client.

• “Other Relative:” Includes family members such as cousins, nieces/nephews, etc.

• “Other Non-Relative:” Includes friends, neighbors, former spouses, etc. 

124. Caregiver Address: Note the caregiver’s address in each lettered field provided (including the 

a. street, b. city, c. state, and d. ZIP code). 

125. Caregiver Telephone Number: Note the caregiver’s telephone number in the space provided. 

The phone number includes the area code and the seven-digit phone number. Leave this item blank 

if the caregiver does not have a telephone number. 

If the caregiver has multiple numbers (i.e., a number for home, cell, and work), note the best 

way to reach them on Question 125, and document the other numbers in the “Notes & 

Summary” space provided.

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126. Caregiver Employed Outside Home: Indicate whether the caregiver is employed outside the 

home (“No” or “Yes”). If the response is “No,” skip to Question 127. If “Yes,” indicate whether this 

employment is “Full-time” or “Part-time” by checking the appropriate box. 

Caregivers who are working at a full-time job, or a part-time job, or are at home with the 

client all of the time will each have differing needs to which the Assessor/Case Manager will 

need to be sensitive. For example, a caregiver who is still working may be unable to provide 

immediate assistance to the client, or may have periods of time where they are unavailable.

127. Caregiver Assistance: Ask the caregiver if they currently have someone to assist in providing 

care (“No” or “Yes”). This could be a second caregiver, a neighbor, or friend who could fill in if the 

caregiver were temporarily away. If they do not have assistance (“No”), skip to Question 129. If the 

response is “Yes,” ask Question 128.

128. Caregiver Assistance Contact Information: If the caregiver has someone to assist in providing 

care, ask whether you have her/his permission to contact this person if for some reason the caregiver 

is unable to provide care for the client (“No” or “Yes”). If the response is “No,” skip a-d. If the caregiver 

gives her/his permission (“Yes”), record the contact information: a. First name, b. Last name, c. Phone 

number, and d. Relationship to the client (“Wife,” “Husband,” “Partner,” “Parent,” “Son/In-law,” 

“Daughter/In-law,” “Other relative,” or “Other Non-relative”). 

129. Length of Time as Caregiver: Indicate how long the caregiver has been providing care for this 

client (“Less than 6 months,” “6 to 12 months,” “1 to 2 years,” or “2 or more years”). The likelihood of 

caregiver burn out may be able to be determined by how long the caregiver has been caring for this 

client. If the caregiver previously cared for another client long-term, that should be noted in the case 

narrative for this visit.

130. Hours per Week as Caregiver: Note the number of hours per week that the caregiver currently 

spends providing care for the client in the space provided. 

131. Training or Assistance: Indicate if the caregiver thinks they would benefit from additional 

training or assistance in performing their caregiving tasks (“No” or “Yes”). If “Yes,” describe the type of 

training or assistance the caregiver would be interested in on the line provided.

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The availability, cost, variety, and schedule of training opportunities varies widely throughout 

different areas of the state. Additional research may be needed to identify local resources.

132. Strain on Caregiver: Ask the caregiver how much of a mental or emotional strain caring for the 

client places on her/him and mark the appropriate response (“None,” “Some Strain,” or “A lot of 

strain”). There are numerous OAA resources available through the ADRC to refer caregivers that 

answer “Some Strain” or “A lot of strain” to, as appropriate.

133. Caregiver Difficulties: Ask the caregiver to rate the level of difficulty they have with the eight 

items listed (a through h) on a scale of “No difficulty,” “Little difficulty,” “Some difficulty,” “Moderate 

difficulty,” or “A lot of difficulty:”

a. “Relationship with client” – Since they began caregiving, have they experienced any 

difficulties in their relationship with the client? 

b. “Relationship with family” – Has caregiving impaired their relationships with their family? 

c. “Relationships with friends” – Have caregiving responsibilities prevented socialization with 

their friends?

d. “Physical health” – Has caregiving negatively affected their physical health?

e. “Finances” – Has caregiving caused difficulties in paying their bills or managing their 

finances?

f. “Functional abilities” – Has caregiving affected their ability to function? Have they had 

difficulties managing their own life? 

g. “Employment” – If the caregiver does not work, the response should be based on whether 

they want/need to work but do not as a result of their caregiving demands. If the 

caregiver does work, the response will be based on the impact their caregiving has on 

performing their job-related duties.

h. “Time for yourself, to do the things you enjoy” – Has caregiving interfered with their 

personal time and hobbies, etc.?

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134. Confidence in Ability for Continued Care: Indicate how confident the caregiver is that s/he will 

have the ability to continue to provide care for the client (“Very confident,” “Somewhat confident,” 

or “Not very confident”). If the response is “Very confident” or “Somewhat confident,” skip question a.

If the caregiver is “not very confident” in her/his ability to continue providing care, ask question a. 

a. Reason for Lack of Continued Care: Detail the main reason why the caregiver may be 

unable to continue to provide care for the client in the space provided. 

135. Assessor/Case Manager: Is the Caregiver in Crisis?: Indicate your evaluation of the primary 

caregiver’s ability and/or willingness to continue to provide the care needed by the client. They may 

be unable and/or unwilling due to their own limitations and/or those of the client. The crisis may 

already be in effect or may be quickly approaching. If you determine the primary caregiver to be in 

crisis, mark “Yes” and note if that crisis is for a “Financial,” “Emotional,” and/or “Physical” reason, or 

some combination of these.

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136. Caregiver Perceptions of Changes in Client Memory: This screening tool is based on the AD8 

and has been validated against a clinical diagnosis for dementia. Ask the caregiver to answer 

questions a-h about the client, providing instruction that an answer of “Yes, a change” indicates that 

the caregiver has noticed a change in the last year in the client’s thinking or memory function. If the 

caregiver does not know if there has been a change, or if they do not know how to answer an item, 

mark “N/A.” If the client’s thinking or memory has improved, mark “N/A.” 

The AD8 is an 8-item questionnaire that is designed to detect dementia. It is considered a strong 

instrument for self-administration or informant-based assessment. Used in this instance, the AD8 is 

a tool for use with an informant (usually a spouse, child, or non-family caregiver) to assess 

whether they have noticed changes in certain areas of the client’s cognition and functioning.

The AD8 is quite sensitive to detecting early cognitive changes associated with many common 

illnesses, including Alzheimer’s disease, vascular dementia, Lewy body dementia, and 

frontotemporal dementia. However, if a client has been experiencing memory loss symptoms, 

they will need to see a physician for a diagnosis.

Florida Assessment Instructions and Attachments 130
701D INSTRUCTIONS 

ATTACHMENT A: 

Social Security Number Handout 

Florida Assessment Instructions and Attachments 131
 

WHY ARE WE COLLECTING YOUR SOCIAL 

SECURITY NUMBER? 

We are required to explain that your Social Security number is 

being collected pursuant to Title 42 Code of Federal 

Regulations, Section 435.910, to be used for screening and 

referral to programs or services that may be appropriate for you. 

 

The provision of your Social Security number is voluntary, and 

your information will remain confidential and protected under 

penalty of law. We will not use or give out your Social Security 

number for any other reason unless you have signed a separate 

consent form that releases us to do so. 

Florida Assessment Instructions and Attachments 132
701D INSTRUCTIONS 

ATTACHMENT B: 

HCE Safety & Accessibility Worksheet 

Florida Assessment Instructions and Attachments 133
DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK 

Chapter 7: Administration of the Home Care for the Elderly Program 

7-47 

July 2011 

Attachment 4: Optional HCE Safety and Accessibility Worksheet 

OPTIONAL HCE SAFETY AND ACCESSIBILITY WORKSHEET: 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Structure of Home, Floors—Overall Risk 

Exposed Wiring 

Creaking or uneven floors 

Ceilings with water marks 

Doors open with difficulty 

Windows cannot be opened 

Outside structure appears to be leaning 

Questions and Responses:

1. How old is your home? 

Response: 

2. Have you or your caregiver consulted anyone about problems with the structure of 

the home? 

Response: 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Access—Overall Risk 

Client lives above the 1st floor of the building 

Client lives above the 1st floor of the building with no 

elevator 

 

Client has limited/deteriorating mobility 

Client lives in 2-story home with bedrooms upstairs 

Client cannot climb stairs 

Client uses a wheelchair for mobility 

Entrance to the home has steps 

Doorways are too narrow, rooms to small to safely 

maneuver 

 

Question and Response:

1. If the client uses a wheelchair for mobility, ask how he/she is able to maneuver 

within and in and out of the home? 

Response: 

Florida Assessment Instructions and Attachments 134
DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK 

Chapter 7: Administration of the Home Care for the Elderly Program 

7-48 

July 2011 

Attachment 4: Optional HCE Safety and Accessibility Worksheet 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Electrical System—Overall Risk 

Electrical cords are frayed 

Extension cords are overused 

Electric plugs are partially hanging out of the wall 

The wiring in the home is poor 

Questions and Responses:

1. Have you or your caregiver ever been shocked trying to plug or unplug anything? 

Response: 

2. Do you have to change fuses frequently? 

Response: 

3. Has your electric bill increased significantly even though you are not using more 

appliances? 

Response: 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Fire Safety—Overall Risk 

Wall-to-wall clutter 

Client and/or caregiver smoke 

No smoke alarms or alarms do not work (no batteries) 

Use of non-vented space heater 

Fireplace used without a screen guard 

Questions and Responses:

1. Have you or your caregiver ever fallen asleep while smoking? 

Response: 

2. Do you or your caregiver forget food cooking on the stove on in the oven? 

Response: 

3. Do you have a fire extinguisher and do you know how to use it? 

Response: 

4. Have you checked the smoke alarm and changed the batteries lately? 

Response: 

5. Do you use a timer to set when using the oven or toaster over? 

Response: 

Florida Assessment Instructions and Attachments 135
DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK 

Chapter 7: Administration of the Home Care for the Elderly Program 

7-49 

July 2011 

Attachment 4: Optional HCE Safety and Accessibility Worksheet 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Sanitation—Overall Risk 

Unpleasant odor in the house 

House is unclean 

Bathrooms are unclean and odorous 

Furniture/carpet are soiled 

Evidence of pest or pest’s droppings in the house 

Evidence of dead pest odor 

Evidence of pet odor 

Questions and Responses:

1. Do you have pest control service? 

Response: 

2. Do you have pests in the house such as roaches, rats or mice? 

Response: 

3. Do you use sprays or tablets for control? 

Response: 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Hot Water/Water—Overall Risk 

Evidence of excessive amounts of dirty dishes from 

lack of water 

Client is unkempt, unclean and has body odor 

Client’s clothing is unclean 

Questions and Responses:

1. Do you have running water? 

Response: 

2. Do you have hot water? 

Response: 

Additional Comments: 

Florida Assessment Instructions and Attachments 136
DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK 

Chapter 7: Administration of the Home Care for the Elderly Program 

7-50 

July 2011 

Attachment 4: Optional HCE Safety and Accessibility Worksheet 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Heating/Air Conditioning—Overall Risk 

Temperature in the house is too warm or cold 

Room is stuffy even with air conditioner on 

Questions and Responses:

1. How do you keep warm in the winter? 

Response: 

2. Do you have a central air and heating system? Does it work adequately? 

Response: 

3. Do you have to unplug another appliance to run a space heater or air conditioner? 

Response: 

4. Do you sleep with a space heater on at night? 

Response: 

5. Does the heat bother you in the warm months? 

Response: 

6. Why don’t you run your air conditioner? 

Response: 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Shopping Accessibility—Overall Risk 

Evidence of little or no food in cabinets/pantry/refrigerator 

Evidence of prescriptions not filled 

Questions and Responses:

1. How do you do your shopping/errands? 

Response: 

2. When was your last trip to the grocery store? 

Response: 

3. Can you afford to pay someone to do your shopping and pick up your 

prescriptions? 

Response: 

Florida Assessment Instructions and Attachments 137
DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK 

Chapter 7: Administration of the Home Care for the Elderly Program 

7-51 

July 2011 

Attachment 4: Optional HCE Safety and Accessibility Worksheet 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Transportation Accessibility—Overall Risk 

Client is unable to get to local transportation pickup 

Client does not drive or have anyone who can drive 

him/her. 

 

Caregiver does not drive 

Questions and Responses:

1. How do you and your caregiver get to stores to shop, run errands? 

Response: 

2. Is transportation available from other local agencies? 

Response: 

3. Are you able to get on a bus? 

Response: 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Telephone Accessibility—Overall Risk 

No telephone is visible 

No phone number is listed on the referral 

Questions and Responses:

1. Are you able to afford a telephone? 

Response: 

2. Is the client able to use the telephone? 

Response: 

3. Are you able to use a neighbor or friend’s phone? 

Response: 

4. How can I reach you or you reach me when necessary? 

Response: 

5. How do you get help in an emergency? 

Response: 

6. May I contact your family to discuss the possibility of getting you a telephone? 

Response: 

Florida Assessment Instructions and Attachments 138
DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK 

Chapter 7: Administration of the Home Care for the Elderly Program 

7-52 

July 2011 

Attachment 4: Optional HCE Safety and Accessibility Worksheet 

AREA OF CONCERN No 

Risk 

Low 

Risk 

Moderate 

Risk 

High 

Risk 

Emergency Evacuation Capability—Overall Risk 

The doors and windows are boarded up, nailed shut, 

covered with burglar bars or otherwise will not open. 

The client is unable to walk, transfer to a wheelchair, open 

doors or manage stairs, making evacuation attempts 

impossible 

 

Exit access is obstructive (clutter, furniture, etc.) 

Client’s bedroom does not have two means of unobstructed 

exit 

 

Questions and Responses:

1. Do you feel that you could evacuate the home safely in an emergency? 

Response: 

2. Can you describe what you would do in case of an emergency? 

Response: 

3. Would the caregiver be able to get both himself/herself and the client out of the 

home in the case of an emergency? 

Response: 

Additional Comments: 

Florida Assessment Instructions and Attachments 139
KDOA Form SS-005 Revised 7/01/10 

AAA/CME ___________

Assessor Name

_____________________________

Assessor Phone

_____________________________

Disaster Red 

Flag

Electric

Physical Impairment

Medication Assist

Cognitive/MH issues

No Informal Support

None

Assessment Date : Expedited Services : Yes _____ No _____

Customer Legal Name & Address: Nickname ____________________

First ______________________________________________ M.I. _________

Last _____________________________________________________________

Residence Address ______________________________________________

City ______________________________________________________________

County _______________ State ___________ Zip _______________ 

Phone __________________________________________________________

Directions ________________________________________________________

__________________________________________________________________

...........................................................................................

Mailing or Alternative Address

Street ____________________________________________________________

City ______________________________________________________________

County _______________ State ___________ Zip _______________

Phone __________________________________________________________

 

Birth Date _________ / ________ / __________

 month day year

Age ____________ Male ____ Female ____

Marital Status: Single ____ Married ____ 

 Widowed ____ Divorced ____

Veteran or Spouse of Veteran? Yes ___ No ___

Receive Veteran Benefits? Yes ___ No ___

Income below poverty level? Yes ____ No ____

Does Customer live alone? Yes ____ No ____

Customer’s home is: Rural ____ Urban ____

Ethnicity: Hispanic or Latino ____ 

 Not Hispanic or Latino ____ 

 Ethnicity Missing ____

Race:

White Non-Hispanic

White Hispanic

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Reporting some other race

Reporting 2 or more races

Social Security # ____________________________________________

Medicaid # __________________________________________________

Medicare # _________________________________________________ 

KAMIS ID # _________________________________________________

Primary Language Speaks Reads Understands 

Orally

 English

 German

 Spanish

 Sign

 Other:

Does Customer have any difficulty :

 Communicating

 Understanding information

Emergency or alternative contact: Relationship __________________

Name ___________________________________________________

Address _________________________________________________

City ____________________________________________________

State _____________________ Zip ___________________ 

Phone (primary) ________________________________________

Phone (alternate) ________________________________________

Legal Guardian: Relationship ________________________

Name ___________________________________________________

Address _________________________________________________

City _____________________________________________________

State _____________________ Zip ___________________ 

Phone (primary) ________________________________________

Phone (alternate) ________________________________________

Comments:_________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Kansas Department for Aging

and Disability Services

Uniform Assessment Instrument

Kansas Uniform Assessment Instrument 140
KDOA Form SS-005 05/01/2006 

UAI – Page 2 – Functional 

Customer Name _________________________________________________ Date __________________________ 

Uniform Assessment Instrument Scoring Long-term Care Threshold Guide

Definition of Code for Cognition Code

 

 Multiplier for Threshold Guide

Sum of Cognition scores

 No impairment 0 0

 Impairment 1 1

 Unable to test 9 0

Cognition Cog. Code Multiplier X Weight = Total

Sum of 

Cog. 

scores

 Orientation (day of the week, month, year, President) X 2 =

 3-word recall (pen, car, watch) X 2 =

 Spelling backward (table) X 2 =

 Clock Draw ( all #’s, spacing of #’s, hands at 11:10) X 2 =

Definition of Code for ADL/IADL Code

 

 Multiplier for Threshold Guide

 Independent 1 0

 Supervision Needed 2 1

 Physical Assistance Needed 3 1

 Unable to Perform 4 2

Activities of Daily Living ADL Code Multiplier X Weight = Total

Sum of 

ADL 

scores

 Bathing X 4 =

 Dressing X 3 =

 Toileting X 5 =

 Transferring X 5 =

 Walking, Mobility X 3 =

 Eating X 4 =

 

Instrumental Activities of Daily Living IADL Code Multiplier X Weight = Total

Sum of 

IADL 

scores

 Meal Preparation X 5 =

 Shopping X 3 =

 Money Management X 4 =

 Transportation X 3 =

 Telephone X 3 =

 Laundry, Housekeeping X 3 =

 Medication Management, Treatment X 5 =

RISKS: Current or Recent Problems (check all that apply) Risk Code Multiplier X Weight = Total

Sum of 

RISKS 

scores

 Falls (Last 1 month _____) (Last 6 month total _____) 1 X 3 =

 Neglect abuse and/or exploitation by others 1 X 5 =

 Informal Support – check appropriate choice If customer has difficulty in the informal 

support category, enter 4 at total:

 Yes – there is support (do not multiply out)

 Inadequate Multiplier X Weight = Total

 No – there is no support 1 X 4 =

 Behavior - check the appropriate choice(s) if any difficulty If customer has difficult in any behavior 

category, enter 5 at total:

 Wandering Multiplier X Weight = Total

 Socially Inappropriate/Disruptive

1

X 5=

 Decision Making/Judgment 

 

 Total Score of all Cognition, ADL, IADL and RISKS for Threshold Guide =

 Was this person on HCBS-FE prior to 7-1-00? Yes No Is this a HCBS-PD transfer customer? Yes No 

Comments : ____________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

Kansas Uniform Assessment Instrument 141
KDOA Form SS-005 07/01/10 

UAI – Page 3 – Nutrition 

Customer Name _______________________________________________ Date _______________________________ 

Ask the customer the following questions

Nutrition Risk Screen Comments

Score-if 

yes, circle

Do you eat less than 2 meals daily? 3

Do you eat less than 2 servings of fruits and vegetables daily? 1

Do you eat less than 2 servings of dairy products (milk, cheese, yogurt, etc.) daily? 1

Do you usually drink less than 6 glasses of water, milk, or juice daily? # of glasses: 0

Do you drink 3 or more alcoholic beverages daily? 2

Do you take 3 or more different prescriptions and/or over-the-counter drugs daily? 1

Do you have problems with dentures, teeth, or mouth, which make it hard to eat? Which: 2

Have you made changes in the kind and/or amount of food you eat because of an 

illness and/or condition?

What changes:

2

Are you physically not always able to grocery shop, cook, and/or feed yourself? Which: 2

Do you eat alone most of the time? 1

Do you feel that you usually do not have enough money to buy the food you need? 4

Have you gained or lost more than 10 pounds in the last 6 months? Pounds gained ____ lost ____ 2

Customer does not meet any of the nutrition risk screen indicators. 0

 Add all the circled scores for a total Nutrition Risk Score

Would you say that your appetite is: Do any of the following cause you problems or affect your ability to eat:

 Good Swallowing

 Fair Taste

 Poor Nausea, vomiting

Comments: _____________________________

_________________________________________

_________________________________________

 Cutting up food

 Opening containers (milk, plastic wrap, jars)

 Certain foods, food allergy (specify):

 No concerns

How often do you:

Rarely

1 x week

Sometimes

2 x week

Frequently

4-5 x week Never

 Skip meals and just snack, “piece”, through the day?

 Lack the energy or desire to fix a meal?

 Find you don’t know what to fix or can’t fix small portions?

 Forget to turn the stove off or burn food?

 Lack the desire to eat a meal?

 Eat restaurant or fast food?

 Leave home?

 If not, why?

What do you eat in a typical day (ask about "breakfast", "lunch", "supper"), describe: ___________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Comments (include any special considerations for service delivery such as pets, or "go to back door"): ___________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Kansas Uniform Assessment Instrument 142
KDOA Form SS-005 (Revised 04/01/09) 

UAI – Page 4 – Nutrition 

Customer Name ________________________________________________ Date _____________________________ 

Ask the customer:

Does anyone help you prepare food or bring food to you? Yes No If yes, answer the following:

Who What When

Ask the customer:

Are you following any modified diet(s)? Yes No Are any of the modified diets doctor prescribed? Yes No

Check each modified diet followed:

 

 Check if doctor prescribed and indicate the name of the doctor:

 Low sodium (salt)

 Low sugar

 Low fat/cholesterol

 Renal

 Calorie controlled

 Nutrition supplements

 6 small meals daily

 Vegetarian

 Pureed

 Ethnic/religious

 Other:

Assessor:

Is the customer: Yes No 

Participant Status - Home-delivered Meals

 60+ eligible Person

 Physically homebound Spouse, regardless of age, of 60+ eligible Person

 Socially homebound Disabled Person, regardless of age, residing with 60+ eligible Person 

 Isolated 60+ non-spouse Caretaker (IIIB home-delivered meals only)

Clock Draw 

Kansas Uniform Assessment Instrument 143
KDOA Form SS-005 10/1/99 

UAI – Page 5 – Health 

Customer Name ________________________________________________ Date ___________________________ 

Primary Diagnosis ______________________________________________ 

Source of Information: Customer Record Review Other 

Customer: Overall, how do you rate your health? Excellent Good Fair Poor 

Check Health Conditions as Applicable

CARDIOVASCULAR INFECTIOUS DISEASE RESPIRATORY

 Ankle edema Airborne Asthma

 By-pass surgery/Angioplasty Hepatitis COPD

 Chest pain Tuberculosis Cough (dry/productive)

 Circulation problems Other Difficulty breathing at any time 

 Congestive heart failure No problem Emphysema

 Heart attack Oxygen

 Hypertension MUSCULOSKELTAL Other

 Hypotension Amputation of: No problem

 Pacemaker Arthritis-rheumatoid or osteo

 Shortness of breath Back pain SKIN

 Other Contractures Pressure/other ulcer

 No problem Fracture of: Rashes

 Joint replacement of: Shingles

ENDOCRINE Osteoporosis Stasis dermatitis

 Diabetes Polio/Post Polio Other

 Thyroid Other No problem

 Other No problem

 No problem VISION

NEUROLOGICAL Blind

GASTROINTESTINAL Alzheimer’s disease Blurred vision

 Abdominal pain Cerebral Palsy Cataracts

 Colitis CVA/stroke Corrective lenses

 Constipation Dementia Glaucoma

 Diarrhea Dizziness Macular degeneration

 Difficulty swallowing Paralysis of: Other

 Diverticular disease Parkinson’s Disease No problem

 Frequent use of laxatives Seizures/epilepsy

 Gall bladder problems Speech problem OTHER

 Indigestion Transient Ischemic Attack Alcohol use

 Irritable bowel syndrome Traumatic brain injury Alcoholism

 Ulcers Other Allergies

 Other No problem Anemia

 No problem Autism

REPRODUCTIVE SYSTEM Cancer

GENITOURINARY Enlarged prostate Developmental disability

 Dialysis Lumps-breast/node(male, female) Drug use/abuse

 Difficulty/frequent urination Mastectomy of: Mental illness

 Dribbling and/or incontinence Nipple discharge (male, female) Mental retardation

 Frequent bladder infections Prostate cancer Tobacco use

 Nighttime urination/Nocturia Vaginal discharge Obesity

 Other Other Significant weight loss/gain

 No problem No problem Other

 No problem

HEARING

 Deaf COMMENTS:

 Decreased acuity

 Earaches

 Hearing aid

 Other

 No problem

Kansas Uniform Assessment Instrument 144
KDOA Form SS-005 10/1/99 

UAI – Page 6 – Health 

Customer Name __________________________________________________ Date ___________________________ 

Prescription, Over-the-counter, & 

Herbal Medications/Preparations 

Dosage Frequency

Does the 

customer know 

the purpose of 

the medication?

How does the customer 

remember to take 

medications?

(check all that apply) Yes No

 Calendar

 Person reminds/gives

 Egg carton/envelope

 Pill box or dispenser

 Follow label directions

 Other:

 Other:

If set-up, reminded, or given by 

another, by whom? How often? 

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

Does the customer have any drug sensitivities? Yes No If yes, what: __________________________________________

______________________________________________________________________________________________________________________

Assessor: Do you have any concerns regarding use of medication or drugs by the customer? Yes No If yes, 

what concerns: _______________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Ask the customer the following questions: Yes If yes, then ask: No

Do you have a "Durable Power of Attorney for Health 

Care Decisions"?

Who?

Do you have a "Living Will"? Where?

Do you have "Do Not Resuscitate" orders? Where?

Do you see a doctor regularly? How often?

Have you been hospitalized or to the emergency room 

in the last three months?

How many times?

Have you been admitted to a nursing home within the 

last twelve months?

How many times?

Comments: __________________________________________________________________________________________________________

SPECIAL EQUIPMENT/ASSISTIVE DEVICES (check all that apply)

Uses Needs Uses Needs

 Adaptive eating equipment Medical phone alert

 Bathing equipment Ramps (example – wheelchair)

 Brace (leg, back), prosthesis Supplies (example – incontinence pads)

 Cane, crutches Toilet equipment

 Dentures Transfer equipment

 Diabetic supplies Walker

 Glasses, contact lenses Wheelchair (manual, electric)

 Hearing aid(s) Other:

 Hospital bed Other:

Kansas Uniform Assessment Instrument 145
KDOA Form SS-005 05/01/2006 

UAI – Page 7 – Health 

Customer Name ______________________________________________ Date ________________________________ 

Assessor: Ask the customer how he/she has been feeling during the past 4 weeks. For each question, please 

mark the level that best describes how often she/he had this feeling.

In the last 4 weeks, about how often did you feel....

All of 

the 

time

(4 pts)

Most 

of the 

time

(3 pts)

Some 

of the 

time

(2 pts)

A little 

of the 

time

(1 pt)

None 

of the 

time

(0 pt)

Don’t 

know

(0 pt)

Refused

(0 pt)

... so sad that nothing could cheer you up?

... nervous?

... restless or fidgety?

... hopeless?

... everything was an effort? (If necessary, for question 

e.g., prompt: How often did you feel everything was hard 

and difficult to do?)

... worthless?

 (Score 13 or higher, offer a referral for your customer) Total Score

In the past 4 weeks, how many times have you seen a doctor or other health professional about these feelings?

No visits reported_____ Number of visits _____ Don’t know _____ Refused _____

Comments:_______________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Ask the customer:

Have there been any major changes, or disruptions 

in your life that you would like to talk about? 

Yes No If yes, what: _________________________

_____________________________________________

_____________________________________________

Do any items checked on this page adversely effect:

 Customer

Explain: ______________________

______________________________

______________________________

______________________________

 Caregiver

 Other

 No concerns

Does the customer have a primary caregiver? 

Yes No 

If yes, name: _________________________________________

Is the primary caregiver overwhelmed in providing care?

Yes No If yes, explain in comments.

Comments:_______________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

Medical Personnel Phone Assessor: Are you making or recommending 

Doctor: any referrals to (check all that apply):

 Mental health services 

Pharmacy: Adult Protective Services

 Community Developmental Disability Org.

Home Health: Medical/Home Health

 Other:

Hospital: Other:

 Other:

Comments:_______________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________

Kansas Uniform Assessment Instrument 146
KDOA Form SS-005 10/1/99 

UAI – Page 8 – Environmental/Service Delivery 

Customer Name __________________________________________________ Date ___________________________ 

Place of Residence: Residence Is:

Does the customer have any difficulty getting into their

home or any room in their home (check all that apply): 

 Apartment, condominium Government subsidized Basement

 Assisted living On Reservation Bathing facility, bathtub

 Boarding care home Owned, with payment Bedroom

 Duplex Owned, no payment Entrances

 Home Plus Rented Garage

 Homeless Rent free from ________ Kitchen

 House, townhouse Other Laundry area

 Mobile home Comments: Living, family room 

 Nursing home Porch 

 Residential health care Toilet facility 

 Other No difficulty 

Comments: Comments:

Does the customer’s home 

have: Working

Not 

working

Does not 

have

Does the home have health or physical safety 

issues (check all that apply):

 Air conditioner, fan Animals, pets

 Electricity Dirt, garbage

 Flush toilet Furnishings, rugs

 Gas, propane House, basement

 Heating system Pests

 Microwave Poor lighting

 Piped water, hot/cold Stairs

 Radio, television Yard, storage buildings

 Refrigerator, freezer Other

 Smoke detector No problems

 Stove, hot plate, oven Comments:

 Telephone

 Tub, shower

 Washer

 Dryer Recommended changes to the customer's 

environment and/or situation (check all that apply): Comments:

 Bathroom modification

 Accessibility modification

 Weatherization

Customer: Do you feel safe Yes No Other:

 inside your home Other:

 outside your home No recommendations

Is there anything inside or outside your home 

that you are worried or uncomfortable about? Referrals: ____________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Explain if the customer does not feel safe or if they have 

additional concerns: ________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Are there special considerations for service delivery 

such as smoking, pets, or "go to the back door"? 

Explain: _____________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Kansas Uniform Assessment Instrument 147
KDOA Form SS-005 10/1/99 

UAI – Page 9 – Financial 

Customer Name _____________________________________________ Date ________________________________ 

Family Size (Family will include customer, spouse, and minor children living together.) 

MONTHLY GROSS INCOME

Type of Income Customer Spouse Minor Child Total Comments

(note benefit numbers)

Social Security (SSA)

Social Security Disability (SSD)

Supplemental Security Income (SSI)

Retirement pension

Veteran pension

Gross earnings from employment, 

self-employment

Income from property

Farm income (adjusted net income)

Interest, dividends

Coop dividends, royalties, etc.

Regular support from family/others

Cash from SRS

Other

Other

 Monthly Total Income

(Remember to check poverty level on page 1)

Percent of customer responsibility for co-pay program: Name/address if bill for co-pay is to be sent to someone other than customer:

SCA ____________ % _____________________________________________________________

 IE ____________ % _____________________________________________________________

 Other ____________ % _____________________________________________________________

Customer: Do you need legal assistance? Yes No 

Customer: Do you want a referral for SRS assistance?

 Financial: Yes No Already received 

 Medical: Yes No Already received 

 Food Stamps: Yes No Already received 

EES Specialist: _______________________________________________

Supplemental Insurance:

 Company ___________________________________________

 Policy # _____________________________________________

 Premium amount $ __________________________________

Designated person for financial matters: Self Other

 Durable Power of Attorney Conservator 

 Relationship ____________________________________________

 Name __________________________________________________

 Address ________________________________________________

 City ____________________________________________________ 

 State ________________ Zip ___________________________

 Phone, home ___________________________________________

 Phone, work ____________________________________________

Comments: ________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Kansas Uniform Assessment Instrument 148
SS-005 page 9(a) Supplemental (10/07)

UAI – Page 9(a) Supplemental – Senior Care Act Financial Worksheet 

Customer Name _____________________________________________ Date ______________________________ 

(1) Does the customer have liquid assets such as Cash (deposited or not), Certificates of Deposit 

(CD), Stocks or Bonds in excess of the following (If unsure complete item #2 below): 

 $10,001 for a 1 Person Family 

 $13,501 for a 2 Person Family 

 $17,001 for a 3 Person Family 

 $20,501 for a 4 Person Family (Exempt $3,500 for each additional person) 

_____ Yes. Proceed to question 2. 

_____ No. Stop, you do not need to proceed. 

_____ Refused to provide income or asset information. 

(2) Identify the approximate value for each of the following described assets. 

+____________ Checking/Cash on Hand 

+____________ Savings 

+____________ Bonds 

+____________ Certificates of Deposit (CD) 

+____________ Individual Retirement Account (IRA) 

+____________ Life Insurance (Cash Value) 

+____________ Money Market 

+____________ Mutual Funds 

+____________ Savings Bonds 

+____________ Stocks 

 

Name of Stock

(Name not entered 

in KAMIS)

# of shares x Last sale value = Stock Value

X =

X =

X =

X =

 Total Stock Value ____________ 

(enter this value on stocks) 

============ 

_____________ Total Gross Liquid Assets 

(3) Match the customer’s monthly income (page 9) and gross liquid assets (page 9 Supplemental) 

to the SCA sliding fee scale to determine the percentage the customer is required to pay for 

monthly services. 

____________ Total % of monthly customer responsibility. 

(Record on Page 9 of the UAI) 

Kansas Uniform Assessment Instrument 149
SS-005 page 9b Supplemental 07/01/11 

HCBS/FE EXPEDITED SERVICE DELIVERY FINANCIAL SCREENING WORKSHEET

Customer Name: ______________________________________ Soc. Sec. #: __________________________ 

(1) Does the customer want HCBS? □ Yes, move to 

next question □ No, stop process

(2) Does the customer still plan to apply for Medicaid after Estate 

Recovery is explained to the customer or their legal 

representative?

□ Yes, move to 

next question

□ No, stop process

□ Already has Medicaid, move to 

next question

(3) Is the customer already eligible for SSI? □ No, move to 

next question □ Yes, move to next question

(4) Is the customer already eligible for Medicaid? □ No, move to 

next question □ Yes, move to next question

Question

(A)

Continue If

Checked

(B)

Stop, do not 

Expedite

Section on 

Med. App. 

ES-3100.1

(5) Is the customer a U.S. citizen and a resident of Kansas? □ Yes □ No Section B, p. 2 

and B, p. 1

(6) From Resource Table at bottom of page:

Are the customer’s total resources less than $2,000?

 If the customer has community spouse, are the couple’s 

resources less than or equal to $20,328? 

□ Yes □ No Section I, p. 6, 

7

(7) Does the customer or spouse have a trust fund or an annuity? □ No □ Yes Section I, p. 7

(8) Does the customer or spouse have a life estate in property? □ No □ Yes Section I, p. 7

(9) Has the customer or spouse transferred property within last 5 

years? □ No □ Yes Section I, p. 7, 8

(10) Does the customer have a monthly income of less than $747? □ Yes □ No Section J & K, 

p. 8, 9

(11) Is the customer or spouse self-employed (includes farming)? □ No □ Yes Section J, p. 8

(12) Is the customer’s monthly POC amount less than $4,000? □ Yes □ No UAI p. 10

(13) Does the customer require over the maximum ADL/IADL time 

limits? □ No □ Yes FSM 3.5 Appendix I

EXPEDITE DECISION

If all of the above in 

(A) are checked, 

expedite services 

for this customer.

If at least one of the 

above in (B) is 

checked, do not 

expedite services 

for this customer.

EXPEDITE?

□ Yes

□ No

Resource Table (Source Section I, p. 6, 7, 8) Value

Checking Account $

Savings Account $

Stocks & Bonds $

Funeral Plan or Burial Plan

 Up to $5000/person on an irrevocable plan is exempt plus an additional amount for merchandise, enter non-exempt

amount. $

Burial Plots exempt

Automobiles or other vehicles (Exclude one) $

Life Insurance (exclude term insurance)

 Add together the face value of all policies. If the total is less than or equal to $1,500 they are exempt. If the total is greater than 

$1,500, enter the total of the cash values. $

Home(s)

 If the customer owns a home and resides in it, it is exempt. Enter zero.

 If the customer owns a home but does not reside in it, do they intend to return home?

 If yes, enter zero.

 If no, is there a spouse or dependent child living there?

o If yes, enter zero.

o If no, enter value of non-exempt home. $

Other property (land, buildings) $

Other assets (cash, trailers, boats, oil/mineral rights, NF personal fund account) $

Total Resources $

Kansas Uniform Assessment Instrument 150
UAI – Page 10 – Plan of Care/Support Services 

Customer __________________________________________________________ Address __________________________________________________ Phone # _________________________________________

Medicaid # ____________________________________________ KAMIS ID # __________________________________________ Other agency identifier ________________________________________

Emergency Contact ________________________________________________ Relationship __________________________ Phone: home _______________________ work _______________________ 

AAA/

CME

Service 

Code

Funding 

Source Provider Unit(s) Per

Total

Units 

Monthly

Start Date End Date

Discharge

Code

Cost of 

Unit

Customer 

Obligation/

Copay

Monthly 

Cost

Unmet Need Service Code, Availability Code,

Monthly Number of Units

 

HCBS/FE monthly costs including customer obligation: 

 (HCBS amount must be reported to EES Specialist) +

Service 

Code

AvailabilityUnits Service 

Code

AvailabilityUnits SCA total cost including customer copay: Medicaid Average Acute Care Cost: =

OAA total cost: HCBS/FE Total Cost:

Total customer obligation/copay: 

Release of Information: I consent to the release of the information on this page so I can receive services. I understand the information included in these pages 1-10 will be 

released to Kansas Department for Aging and Disability Services and service providers listed above to enable the delivery of services and program monitoring.

_____________________________________________________ _________________________________ ____________________________________________________

 Customer or Guardian Signature Date Assessor Signature & Phone # 

_____________________________________________________ _________________________________ ____________________________________________________

 Customer or Guardian Signature Date Assessor Signature & Phone # 

Additional Support/Services from Home Health, Family, Friend, Neighbor, Attorney, Landlord, Church, Club, Other

Name

Relationship

(check if primary caregiver)

Address

(indicate "same" if lives with customer)

Phone

Service Frequency

Paid

Home Work Yes No

Kansas Uniform Assessment Instrument 151
South Carolina Client Aging Assessment 152
South Carolina Client Aging Assessment 153
South Carolina Client Aging Assessment 154
South Carolina Client Aging Assessment 155
South Carolina Client Aging Assessment 156
South Carolina Client Aging Assessment 157
South Carolina Client Aging Assessment 158
South Carolina Client Aging Assessment 159
South Carolina Client Aging Assessment 160
South Carolina Client Aging Assessment 161
South Carolina Client Aging Assessment 162
South Carolina Client Aging Assessment 163
South Carolina Client Aging Assessment 164
South Carolina Client Aging Assessment 165
South Carolina Client Aging Assessment 166
South Carolina Client Aging Assessment 167
South Carolina Client Aging Assessment 168
South Carolina Client Aging Assessment 169
South Carolina Client Aging Assessment 170
SAMS ILA (NSI) 2010

0. Cover Sheet

0.A. Client Identification

1. What is the date of the assessment?

______/______/____________

2. Specify the type of assessment, or the reason for the 

assessment.

1 - Initial assessment

2 - Reassessment

3. Where was the client interviewed?

1 - Home

2 - Hospital

3 - Nursing facility

4 - Other

4. Describe where the client was interviewed.

5. What is the name of the person conducting this 

assessment?

6. What is the name of the agency the assessor works 

for?

7. What is the client's last name?

8. What is the client's first name?

9. What is the client's middle initial?

10. Enter the client's name suffix.

11. Enter the client identifier for the client.

12. Enter the client's 'also known as' name.

13. What is the client's ethnicity?

1 - Hispanic or Latino

2 - Not Hispanic or Latino

3 - Unknown

14. What is the client's race?

1 - American Indian/Native Alaskan

2 - Asian

3 - Black/African American

4 - Native Hawaiian/Other Pacific Islander

5 - Non-Minority (White, non-Hispanic)

6 - Hispanic/Latino - White

7 - Other

15. Enter the client's telephone number.

16. What is the client's Social Security Number?

_________-_________-____________

17. What is the client's date of birth?

______/______/____________

18. Enter the age of the client in years.

19. What document was used to verify the client's age?

Birth certificate

Driver's license

Employment identification card

Military/veteran's identification card

Notarized affidavit

Passport

Self Declaration (Must Complete Age Declaration on 

Signature Page)

Social Security or Medicare card

U.S. census records

Wedding or divorce decree

Other (Answer Next Question if this is chosen)

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20. What other document was used to verify the client's 

age?

21. What is the client's gender?

M - Male

F - Female

22. Enter the client's residential street address or Post 

Office box.

23. Enter the client's residential city or town.

24. Residential zip code.

25. What county does the client reside in?

26. If different from residential address, enter the 

client's mailing street address or Post Office box.

27. If different from residential address, enter the 

client's mailing city or town.

28. If different from residential address, enter the 

client's mailing state.

29. If different from residential address, enter the 

client's mailing ZIP code.

30. What is the name of the client's caregiver?

31. What is the relationship of the primary helper to the 

client?

Daughter/Daughter-in-law

Grandparent (55+)

Husband

Non-relative

Other elderly non-relative (60+)

Other elderly relative (60+)

Other relative

Relationship Missing

Son/Son-in law

Wife

0.B. Emergency Contact Information

1. What is the name of the client's primary care 

physician?

2. What is the work phone number for the client's 

primary care physician?

3. Name of Friend or Relative (other than 

Spouse/Partner) to contact in case of an Emergency.

4. Relationship of Friend or Relative (other than 

Spouse/Partner) to contact in case of an Emergency.

5. Address of Friend or Relative (other than 

Spouse/Partner) to contact in an Emergency.

6. Work Telephone Number of Friend or Relative (other 

than Spouse/Partner) to contact in case of an Emergency.

7. Home Telephone Number of Friend or Relative (other 

than Spouse/Partner) to contact in case of an Emergency.

8. Cell Number of Friend or Relative (other than 

Spouse/Partner) to contact in case of an Emergency.

9. What is the name of a second relative or friend of the 

client?

10. What is the work phone number of the second 

relative or friend of the client?

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11. What is the home phone number of the second 

relative or friend of the client?

12. What is the e-mail address of a Family Member?

0.C. Directions to Client's Home

Directions on how to get to the client's home.

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1. Intake

1.A. Standard Data

1. Did someone help the client or answer questions for 

the client?

Y - Yes

N - No

2. What is the name of the person that helped the client 

during this assessment?

3. What is the helper's relationship to the client?

4. Was communication/language assistance needed for 

this assessment?

Y - Yes

N - No

5. Specify the client's primary language.

English

Spanish

French

Italian

German

Russian

Other

6. What type of communication/language assistance 

was needed for this assessment?

1.B. Legal Representative

1. Does the client have a power of attorney?

Y - Yes

N - No

2. What is the name of the client's power of attorney?

3. Enter the work phone number of the client's power of 

attorney.

4. Enter the home phone number of the client's power 

of attorney.

5. Does the client have a DPOA for health care?

Y - Yes

N - No

6. What is the name of the client's DPOA for health 

care?

7. Enter the work phone number of the client's DPOA 

for health care.

8. Enter the home phone number of the client's DPOA 

for health care.

9. Does the client have a DPOA for finances?

Y - Yes

N - No

10. What is the name of the client's DPOA for finances?

11. Enter the work phone number of the client's DPOA 

for finances.

12. Enter the home phone number of the client's DPOA 

for finances.

13. Does the client have a representative payee?

Y - Yes

N - No

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14. What is the name of the client's representative 

payee?

15. Enter the work phone number of the client's 

representative payee.

16. Enter the home phone number of the client's 

representative payee.

17. Does the client have a legal guardian?

Y - Yes

N - No

18. What is the name of the client's guardian?

19. Enter the work phone number of the client's 

guardian.

20. Enter the home phone number of the client's 

guardian.

21. Does the client have a living will?

Y - Yes

N - No

22. Name of person holding copy of DPOA/Living Will.

23. Telephone number of person holding copy of 

DPOA/Living Will.

24. Address of person holding second copy of 

DPOA/Living Will.

25. If the client does not have a living will, was 

information provided about advanced directives?

Y - Yes

N - No

1.C. Assessment Information

1. Select the client's current marital status.

A - Single

B - Married

C - Separated

D - Widowed

E - Divorced

F - Unavailable

2. Indicate the type of residence that the client 

currently resides in.

A - House/mobile home

B - Private apartment

C - Private apartment in senior housing

D - Residential care home

E - Nursing home

F - Unavailable

Z - Other

3. Is the client NSIP eligible for home delivered meal 

reimbursement? (Regardless of whether or not they need 

meals, if they are over the age of 60 or meet one of the 

conditions on the next question, you will generally check 

yes.)

Yes

No

4. For what reason is the client NSIP eligible for home 

delivered meals?

Disabled individual residing in an elderly housing which 

serves congregate meals

Age 60+ or Tribal Age

Spouse of someone who is NSIP eligible

1.D. Social Screening

1. Select the client's current living arrangement.

A - Lives Alone (3)

B - With spouse/partner

C - Lives with spouse and child

D - With child/children

F - With others (2)

2. If b, c, or d is checked: Ask if any of the person(s) 

that live with you are able to assist with your care? (If 

No, score 2)

No (2)

Yes

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3. What is the name of the client's spouse/partner?

4. How many people are there in the client's household?

A - One person

B - Two people

C - Three people

D - Four or more people

5. Does the client have any children nearby?

Y - Yes

N - No (2)

6. Does the client have contact with family often 

enough?

Y - Yes

N - No (3)

7. Does the client have contact with friends often 

enough?

Y - Yes

N - No (2)

8. Is there a friend or relative that could take care of 

the client for a few days?

Y - Yes

N - No (3)

9. When the client makes a decision about something, 

how does s/he do it?

A - Independently and alone

B - Independently after talking to family/friends (1)

C - Follow advice of family/friends (2)

D - Dependent (3)

E - Information unavailable (Choose only if consumer not 

able to answer score 3)

10. Is the client currently employed?

Yes

No

Full time

11. Is the client participating in any of the following 

services or programs?

Statewide Medicaid Waiver/CHOICES

Homemaker program

Home Health Aide

Nursing

Speech therapy

Occupational therapy

Physical therapy

Home delivered meals

PERS - Personal Emergency Response System

Senior companion

Weatherization

Congregate meals

Adult day services

Food stamps

Fuel Assistance

Telephone lifeline

Medicaid

SSI

QMB/SLMB

QI-1

Personal care

Respite care

Minor Home Repairs

Assistive Devices

Private Duty

504 USDA program

Extra help for Part D Medicare

Other

12. Does the client want to apply for any of the following 

services or programs?

B - Medicaid waiver

C - Homemaker program

I - Home delivered meals

J - Emergency lifeline

L - Weatherization

M - Congregate meals

O - Adult day services

R - Fuel Assistance

T - Medicaid

U - SSI

1 - Personal care

2 - Respite care

3 - Minor Home Modifications

4 - Assistive Devices

5 - Private Duty

O - Other

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Enter Social Score

1.E. Health Screening

1. How does the client rate his/her health?

A - Excellent

B - Good

C - Fair (2)

D - Poor (3)

E - Information unavailable

2. In the past year, how many times has the client 

stayed overnight in a hospital?

1 - Not at all (0)

2 - Once (1)

3 - 2 or 3 times (2)

4 - More than 3 times (3)

3. In the past 6 months has the client stayed in a 

nursing home, residential care home, or other institution?

Y - Yes (2)

N - No

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4. Indicate which of the following conditions/diagnoses 

the client currently has.

Addiction

Alcoholism/substance abuse

Allergies

Alzheimer's disease

Anemia

Ankle/leg swelling

Anxiety disorder

Any psychiatric diagnosis

Aphasia

Arteriosclerosis heart disease (ASHD)

Arthritis/rheumatic disease/gout

Asthma

Blood-related problems

Breathing disorders

Bruises

Cancer

Cardiac dysrhythmias

Cataract

Cerebral palsy

Chronic pain

Chronic weakness/fatigue

Congestive heart failure

Contractures

Coronary artery disease

Decubitus

Deep vein thrombosis

Depression

Developmental disability

Diabetes

Diabetic retinopathy

Dialysis

Digestive problems

Drug resistance (MRSA/VRE)

Edema

Emphysema/COPD/asthma

Expressive communication

Fibromyalgia

Frailty

Frequent falls

Gastritis or related condition

Glaucoma

Hearing impairment

Heart problems

Hemiplegia/Hemiparesis

High cholesterol

Hip fracture

HIV

Hypertension

Hyperthyroidism

Hypotension

Hypothyroidism

Immune system disorders

Incontinence, bladder

Incontinence, bowel

Incontinent

Liver disease

Macular degeneration

Manic depression (bipolar disease)

Memory Loss

Missing limb (e.g., amputation)

Multiple sclerosis

Muscle or bone problems

Nausea/vertigo

Neurological condition

Non-Alzheimer's dementia

Osteoporosis

Other cardiovascular disease

Other eye condition

Other fracture (except hip/spine)

Other neurological

Other significant illness

Paralysis

Paraplegia

Parkinson's disease

Pathological bone fracture

Peripheral vascular disease

Pneumonia

Quadriplegia

Receptive communication

Renal failure

Respiratory disease

Schizophrenia

Seizure disorder

Speech impairment

Stroke

TB

Thyroid disease

Transient ischemic attack (TIA)

Traumatic brain injury

Tremors

Urinary problems

Urinary tract infection

Vision problems

None of the Above

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5. Enter any comments regarding the client's medical 

conditions/diagnoses.

6. Is the client limited in what s/he can do because of 

this health problem?

Y - Yes (3)

N - No

7. How often does bad health, sickness, pain, or 

disability stop the client from doing things s/he would 

like to do?

A - Never

B - Sometimes (1)

C - Often (2)

D - Always (3)

8. Has the client fallen in the past three months?

Y - Yes (3)

N - No

9. In a typical week, during the last 30 days, how often 

did the client go outside of their residence (no matter for 

how short a period of time)?

A - Two or more days a week

B - One day a week or less (2)

10. Does the client use a walker/cane to get around?

Y - Yes (3)

N - No

11. Does the client use a wheelchair to get around or is 

bedbound?

Y - Yes (3)

N - No

12. Does the client have problems with hearing that are 

NOT corrected with aids/devices?

Y - Yes (1)

N - No

13. If the client has hearing aids/devices, are they in 

working order?

Y - Yes

N - No

14. Does the client have problems with vision that are 

not corrected with aids/devices?

Y - Yes (1)

N - No

15. If the consumer uses vision aids/devices, are they in 

working order?

Y - Yes

N - No

16. Does the client have problems with speech that are 

not corrected with aids/devices?

Y - Yes (1)

N - No

17. Describe any aids/devices used by the client to 

correct speech problems.

18. If the consumer uses speech aids/devices are they in 

working order?

Y - Yes

N - No

19. Does the client often feel sad or blue?

Y - Yes (3)

N - No

20. How many prescription medications does the client 

take?

21. Is the number of Medications the client is taking 3 or 

more?

Y - Yes (1)

N - No

22. What was the client's response when asked, 'What 

year is it?'

A - Correct answer

B - Incorrect answer

23. What was the client's response when asked, 'What 

month is it?'

A - Correct answer

B - Incorrect answer

24. What was the client's response when asked, 'Where 

are we now?'

A - Correct answer

B - Incorrect answer

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25. Indicate worker's judgment of client's overall mental 

clarity/cognitive functions.

1 - Good

2 - Fair (2)

3 - Poor (3)

26. In the past six months, has the client lost more than 

10 pounds without trying?

Yes (2)

No

Enter Health Screening Score.

1.F. Nutrition Screening

1. Has the client made any changes in lifelong eating 

habits because of health problems?

Y - Yes (2)

N - No (0)

2. Does the client eat fewer than 2 meals per day?

Y - Yes (3)

N - No (0)

3. Does the client eat fewer than five (5) servings (1/2 

cup each) of fruits or vegetables every day?

Y - Yes (1)

N - No (0)

4. Does the client eat fewer than two servings of dairy 

products (such as milk, yogurt, or cheese) every day?

Y - Yes (1)

N - No (0)

5. Does the client have 3 or more drinks of beer, liquor 

or wine almost every day?

Y - Yes (2)

N - No (0)

6. Does the client have biting, chewing or swallowing 

problems that make it difficult to eat?

Y - Yes (2)

N - No (0)

7. Does the client sometimes not have enough money to 

buy food?

Y - Yes (4)

N - No (0)

8. Does the client eat alone most of the time?

Y - Yes (1)

N - No (0)

9. Does the client take 3 or more different prescribed or 

over-the-counter drugs per day?

Y - Yes (1)

N - No (0)

10. Without wanting to, has the client lost or gained 10 

pounds in the past 6 months?

Y - Yes (2)

N - No (0)

11. Is the client not always physically able to shop, cook 

and/or feed themselves (or able to get someone to do it 

for them)?

Y - Yes (2)

N - No (0)

Total score of Nutritional Risk Questions.

What is the client's nutritional risk score rating?

High risk (6-19)

Moderate risk (3-5)

No risk (0-2)

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2. Functional Assessment

2.A. Activities of Daily Living (ADL)

1. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform 

BATHING (include shower, full tub or sponge bath, 

exclude washing back or hair)?

0 - Independent

1 - Supervision (1)

2 - Requires assistance sometimes (1)

3 - Mostly dependent (1)

4 - Totally dependent (1)

5 - Activity does not occur (1)

Is the help the client receives bathing enough?

Y - Yes

N - No

2. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform 

DRESSING?

0 - Independent

1 - Supervision (1)

2 - Limited Assistance (1)

3 - Extensive Assistance (1)

4 - Total Dependence (1)

5 - Activity did not occur (1)

Is the help the client receives dressing enough?

Y - Yes

N - No

3. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform TOILET 

USE?

0 - Independent

1 - Supervision (1)

2 - Sometimes dependent (1)

3 - Mostly dependent (1)

4 - Totally dependent (1)

5 - Activity does not occur (1)

Is the help the client receives using the toilet enough?

Y - Yes

N - No

4. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform getting 

out of bed/chairs/transferring?

0 - Independent

1 - Supervision (1)

2 - Minimal assistance required (1)

3 - Mostly dependent (1)

4 - Totally dependent (1)

5 - Activity does not occur (1)

Is the help the client receives getting in and out of 

bed/chairs enough?

Y - Yes

N - No

5. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform 

EATING?

0 - Independent

1 - Supervision (1)

2 - Sometimes dependent (1)

3 - Mostly dependent (1)

4 - Totally dependent (1)

Is the help the client receives eating enough?

Y - Yes

N - No

6. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform 

WALKING IN HOME?

0 - Independent

1 - Supervision (1)

2 - Limited Assistance (1)

3 - Extensive Assistance (1)

4 - Total Dependence (1)

5 - Activity did not occur (1)

Is the help the client receives getting around the home 

enough?

Y - Yes

N - No

How many ADL impairments does the client have (Count 

or Total)?

2.B. Instrumental Activities of Daily Living (IADL)

1. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform MEAL 

PREPARATION?

0 - Independent

1 - Sometimes dependent (1)

2 - Mostly dependent (1)

3 - Totally dependent (1)

4 - Activity does not occur (1)

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Is the help the client receives preparing meals enough?

Y - Yes

N - No

2. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform 

SHOPPING?

0 - Independent

1 - Somewhat dependent (1)

2 - Mostly dependent (1)

3 - Totally dependent (1)

4 - Activity does not occur (1)

Is the help the client receives shopping enough?

Y - Yes

N - No

3. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform 

MANAGING MEDICATIONS?

0 - Independent

1 - Needs reminders (1)

2 - Somewhat dependent (1)

3 - Totally dependent (1)

4 - Activity does not occur (1)

Is the help the client receives taking medication enough?

Y - Yes

N - No

4. Specify the client's ability to MANAGE MONEY.

0 - Completely independent

1 - Needs assistance sometimes (1)

2 - Needs assistance most of the time (1)

3 - Completely dependent (1)

4 - Activity does not occur (1)

Is the help the client receives managing money enough?

Y - Yes

N - No

5. Rank the client's ability to use the TELEPHONE.

0 - Independent

1 - Able to perform but needs verbal assistance (1)

2 - Can perform with some human help (1)

3 - Can perform with a lot of human help (1)

4 - Cannot perform function at all without human help (1)

Is the help the client receives using the telephone 

enough?

Y - Yes

N - No

6. Specify the client's ability to perform HEAVY 

HOUSEWORK CHORES.

0 - Independent

1 - Needs assistance sometimes (1)

2 - Needs assistance most of the time (1)

3 - Unable to perform tasks (1)

4 - Activity does not occur (1)

Is the help the client receives performing heavy 

household chores enough?

Y - Yes

N - No

7. Specify the client's ability to perform LIGHT 

HOUSEKEEPING.

0 - Independent

1 - Needs assistance sometimes (1)

2 - Needs assistance most of the time (1)

3 - Unable to perform tasks (1)

4 - Activity does not occur (1)

Is the help the client receives doing housework enough?

Y - Yes

N - No

8. During the past 7 days, and considering all episodes, 

how would you rate the client's ability to perform 

TRANSPORTATION?

0 - Independent

1 - Somewhat dependent (1)

2 - Mostly dependent (1)

3 - Totally dependent (1)

Is the help the client receives using transportation 

enough?

Y - Yes

N - No

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9. Does the client have any of the following devices or 

equipment used to help perform the above ADL/IADL?

Artificial limb

Bath stool

Bedside commode

Cane

Dentures

Extended shower head/Hand held shower

Eyeglasses

Grab bars

Hearing aid

Hospital bed

Lift chair

Nebulizer

Oxygen

Raised toilet seat

Ramp

Walker

Wheelchair

Other

10. Any of Other devices or equipment not listed, if 

other.

How many IADL impairments does the client have (Count 

or Total)?

Total Score (Social + Health+ADL/IADL)

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3. Financial Resources

3.A.i. Client Resources

1. Specify the client's monthly social security income.

 $

2. Specify the client's monthly SSI income.

 $

3. Specify the client's monthly retirement/pension 

income.

 $

4. Specify the client's monthly interest income.

 $

5. Specify the client's monthly VA benefits income.

 $

6. Specify the client's monthly wage/salary/earnings 

income.

 $

7. Specify the client's other monthly income.

 $

3.A.ii. Spouse Resources

1. Specify the monthly social security income of the 

client's spouse.

 $

2. Specify the monthly SSI income of the client's 

spouse.

 $

3. Specify the monthly retirement/pension income of 

the client's spouse.

 $

4. Specify the monthly interest income of the client's 

spouse.

 $

5. Specify the monthly VA benefits income of the 

client's spouse.

 $

6. Specify the monthly wage/salary/earnings income of 

the client's spouse.

 $

7. Specify other monthly income of the client's spouse.

 $

3.A.iii. Total Resources

1. Specify the client's MONTHLY income.

 $

2. What is the client's monthly income?

$1,178 or less

$1,420 or less

$1,662 or less

$695 or less

$937 or less

3. How many people in the household does the client 

support on his/her income?

4. What is the client's TOTAL MONTHLY HOUSEHOLD 

income?

 $

5. Based on the Range, Is the CLIENT'S income level 

below the national poverty level?

Yes

No

3.B. Monthly Housing Costs

1. Specify the client's monthly rent.

 $

2. Specify the client's monthly mortgage.

 $

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3. Specify the client's monthly property tax.

 $

4. Specify the client's monthly heat bill.

 $

5. Specify the client's monthly utilities bill.

 $

6. Specify the client's monthly house insurance cost.

 $

7. Specify the client's monthly telephone bill.

 $

8. Specify the client's other monthly costs.

 $

9. What is the consumer's estimated total medical 

monthly expenses(e.g. health insurance premiums, 

hospital and doctor bills, prescription costs)?

 $

10. Enter the client's total monthly housing expenses.

 $

3.C. Savings/Assets

1. What is the client's savings account/CD/investments 

balance?

 $

2. What is the client's checking account balance?

 $

3.D. Health Insurance

1. Enter the client's Medicare number.

2. Does the client have Medicare A health insurance?

Yes

No

3. Does the client have Medicare B health insurance?

Y - Yes

N - No

4. Does the client have Medigap health insurance?

Y - Yes

N - No

What is the name of the client's Medigap health insurer?

5. Does the client have Medicare D health insurance?

Y - Yes

N - No

What is the name of the client's Medicare D 

company/plan?

6. Does the client have LTC health insurance?

Y - Yes

N - No

What is the name of the client's LTC health insurer?

7. Does the client have other health insurance?

Y - Yes

N - No

What is the name of the client's other health insurer?

3 Comments

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Comment on the client's current financial situation.

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4. Health Assessment

4.A. Current Health Status

1. Describe the client's allergies, if any.

2. Describe the client's special diet(s).

3. Does the client smoke or chew tobacco regularly?

Deferred

Don't know

No

Yes

4.B. Medication Use

1. List all prescribed and non prescribed medications 

taken by the client in the last 7 days.

a. Name and Dose: Record the name of the medication and dose ordered.

b. Form: Code the route of administration using the following list:

1 = by mounth (PO) 7 = topical

2 = sub lingual (SL) 8 = inhalation

3 = intramuscular (IM) 9 = enteral tube

4 = intravenous (IV) 10 = other

5 = subcutaneous (SQ) 11 = eye drop

6 = rectal (R) 12 = transdermal

d. Frequency: Code the number of times per period the med is administered 

using the following list:

PR = (PRN) as necessary OO = every other day

1H = (QH) every hour 1W = (Q week) once each week 

2H = (Q2H) every 2 hours 2W = 2 times every week

3H = (Q3H) every 3 hours 3W = 3 times every week

4H = (Q4H) every 4 hours 4W = 4 times each week

6H = (Q6H) every 6 hours 5W = 5 times each week

8H = (Q8H) every eight hours 6W = 6 times each week

1D = (QD or HS) once daily 1M = (Q month) once/mo.

2D = (BID) two times daily 2M = twice every month

 (includes every 12 hours) C = Continuous

3D = (TID) 3 times daily O = Other

4D = (QID) four times daily

5D = 5 times daily 

a. Name and Dose b. Form c. No. Taken d. Freq e. Comments

1. Continued

2. How does the client remember to take his/her 

medications?

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5. Mental Health/Behavior/Cognition

5.A. Mental Health Services

1. In the past year, has the client received (or is the 

client currently receiving) mental health treatment or 

counseling?

Y - Yes

N - No

2. What kinds of services has the client received, or 

what kinds of services is the client receiving now?

5.B. Behavior

1. Does spouse, partner, caregiver or other person, 

including this assessor, suggest that the client has 

memory or emotional problems?

Y - Yes

N - No

2. How often does the client get lost or wander?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

3. How often is the client physically abusive to 

him/herself?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

4. How often is the client physically abusive to others?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

5. How often is the client verbally abusive to 

him/herself or others?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

6. How often does the client exhibit socially 

inappropriate/disruptive behavior?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

7. How often does the client experience 

hallucinations/delusions?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

5.C. Cognition

1. How often does the client have problems with 

his/her short term memory?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

2. How often does the client have problems making 

him/herself understood?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

3. How often does the client have problems with long 

term memory?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

4. How often does the client have problems 

understanding others?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

5. How often does the client have problems with 

decision making?

1 - Less than daily

2 - Daily

3 - Multiple times per day

4 - Never

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6. Home Environment

6.A. Environmental Checklist

1. Does the client have problems with dangerous stairs 

or floors in his/her home?

Y - Yes

N - No

2. Is it difficult for the client to get to the entrance of 

his/her home?

Y - Yes

N - No

3. Is it difficult for the client to get to the bathroom or 

bedroom in his/her home?

Y - Yes

N - No

4. Does the client have problems with the major 

appliances or toilet in his/her home?

Y - Yes

N - No

5. Does the client have problems with the heating or 

cooling in his/her home?

Y - Yes

N - No

6. Does the client have problems getting water or hot 

water in his/her home?

Y - Yes

N - No

7. Does the client have difficulties keeping his/her 

home free from odor or pests?

Y - Yes

N - No

8. Does the client need a smoke alarm in his/her home?

Y - Yes

N - No

9. Does the client have problems with electrical hazards 

in his/her home?

Y - Yes

N - No

10. Does the client have problems with poor lighting in 

his/her home?

Y - Yes

N - No

11. Does the client have problems with an unsafe stove 

in his/her home?

Y - Yes

N - No

12. Does the client have problems with loose slippery 

rugs in his/her home?

Y - Yes

N - No

13. Does the client have problems with inadequate locks 

on the doors and/or windows in his/her home?

Y - Yes

N - No

14. Does the client have problems keeping his/her home 

clean and free of clutter?

Y - Yes

N - No

15. Does the client have any other environmental 

problems in his/her home?

Y - Yes

N - No

16. Describe any other environmental problems.

17. In the case of an emergency, would the client be able 

to get out of his/her home safely?

Y - Yes

N - No

18. In the case of an emergency, would the client be able 

to summon help to his/her home?

Y - Yes

N - No

19. Comment on the client's home environment in 

general and establish a safety evacuation plan if 

necessary.

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Title : Date 

Title : Date 

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