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Patient Consultation
Functional Assessment

Patient's Name:_____________________________________

Date: _________________

Date of Birth:_________________

Current Living Arrangements:

_____________________________________________________

Relationship to Applicant/Person completing This Form:

_____________________________________________________

Patient 's Medical Diagnoses:

_____________________________________________________

For each area of functioning listed below, please describe to the best of your ability the amount and type of assistance the applicant requires.

BATHING

Does patient take a shower, tub bath or sponge bath?

_____________________________________________________

How often does he/she bathe?

_____________________________________________________

How much assistance is needed?

_____________________________________________________

DRESSING

How much assistance does patient receive in dressing (including selecting and getting clothes from closet, putting on undergarments and using fasteners)?

_____________________________________________________

Additional Comments

_____________________________________________________

TOILETING

Does patient require assistance with toileting (including getting to and from bathroom, cleaning self after elimination and arranging clothes)?

_____________________________________________________

If yes, how much assistance is needed?

_____________________________________________________

Does patient have a catheter? What type?

_____________________________________________________

Does he/she have a colostomy?

_____________________________________________________

Is patient able to control urination?____________ Bowel movements?

_____________________________________________________

If no, how often do "accidents" occur?

_____________________________________________________

MOBILITY

Does patient walk (list assistive devices used, i.e., walker, cane) or does he/she use a wheelchair?

_____________________________________________________

Does he/she need assistance getting out of bed or a chair?

_____________________________________________________

If yes, how much assistance is needed?

_____________________________________________________

EATING

Does patient feed self or require assistance eating?

_____________________________________________________

Does he/she use adaptive equipment while eating (i.e., plate guard, special spoon, etc.)?

_____________________________________________________

Is he/she on a special diet?

_____________________________________________________

How would you describe patient's appetite?

_____________________________________________________

Height_______________________________

Weight_______________________________

MEDICATION

List patient's current medications:

_____________________________________________________

Any known drug allergies?

_____________________________________________________

Is patient using oxygen (if yes, how much and how often)?

_____________________________________________________

PROSTHESES

Does patient have an arm or leg prosthesis?

_____________________________________________________

Does he/she wear dentures (upper and lower)?

_____________________________________________________

Does he/she use a hearing aide?

_____________________________________________________

SKIN

Does patient presently have bed sores (if yes, where and for how long)?

_____________________________________________________

Does he/she have skin rashes?

_____________________________________________________

Does he/she experience swelling of the legs or feet?

_____________________________________________________

ORIENTATION

Is patient alert and oriented or does he/she exhibit confusion? (If confused, is it ongoing, often, or occasional?)

_____________________________________________________

For individuals who are confused and disoriented:

Does the patient attempt to wander?

_____________________________________________________

If yes, how often?

_____________________________________________________

Is he or she willing to return if given direction?

_____________________________________________________

OTHER HEALTH CONSIDERATIONS

Does patient currently use physical or chemical restraints? If yes, describe

type and frequency:

_____________________________________________________

Has he/she ever been hospitalized for any other health problems? If yes, state when, where, and why:

_____________________________________________________

Does patient maintain active and satisfying relationships with family and friends?

_____________________________________________________

Does he/she have a history of drug or alcohol abuse? If yes, please describe:

_____________________________________________________

Is patient currently receiving physical, occupational, speech, or respiratory therapy? If yes, list type of therapy, reason for, and frequency received:

_____________________________________________________

Additional Comments:

_____________________________________________________