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New York State Department of Health ASSISTED LIVING RESIDENCE Division of Home and Community Based Services MEDICAL EVALUATION DOH 3122 (Dev. 03/08) Rev. 1/09 Page 1 of 4 ALL SPACES MUST BE FILLED OUT Facility Name: __________________________________________________________ Date of Exam: ______________ Patient’s/Resident’s Name: ________________________________________ Date of Birth:____________ Sex:__________ Present Home Address: __________________________________________________________________________________ Street ______________________________________________________________________________________________________ City State Zip Reason for evaluation: Pre-Admission 12 month Acute change in patient condition Other (Describe): _______________________________________________________________________________ MEDICAL REVIEW FINDINGS Vital Signs: BP: _______ Pulse:_____ Resp: _______ T: _______ Height: _____ft _____in. Weight: _______ Primary Diagnosis(s): _____________________________________________________________________________ Secondary Diagnosis(s): ___________________________________________________________________________ Allergies: None Known Allergies (list): _____________________________________________________________ Diet: Regular No Added Salt No Concentrated Sweets Mechanical Soft Other: ___________ Does the resident have dental health concerns requiring treatment or which may impair chewing/eating? No Yes If yes, describe:___________________________________________________________________________________ Tobacco Use: PPD/Years: _____________________ Alcohol Use: Amount/Frequency:____________________ Recreational Drug Use: Describe____________________________________________________________________________ IMMUNIZATIONS SCREENINGS Influenza (Date_____________) Mammogram (Date_____________) Pneumococcal Vaccine (Date_____________) Pap Smear (Date_____________) Tetanus Vaccine (Date_____________) PSA (Date_____________) Colonoscopy (Date_____________) TUBERCULIN TEST (Required within 30 days prior to admission unless medically contraindicated) Test is contraindicated TST1:__________Date placed __________Date Read __________mm TST2:__________Date placed __________Date Read __________mm QuantiFERON-TB (QFT):__________Date Placed __________Date Read __________mm Based on my findings and on my knowledge of this patient, I find that the patient _______ IS _______ IS NOT exhibiting signs or symptoms suggestive of communicable disease that could be transmitted through casual contact. CONTINENCE Bladder: Yes No If no, is incontinence managed? Yes No Bowel: Yes No If no, is incontinence managed? Yes No If no, recommendations for management:_______________________________________________________________ New York State Department of Health ASSISTED LIVING RESIDENCE Division of Home and Community Based Services MEDICAL EVALUATION DOH 3122 (Dev. 03/08) Rev. 1/09 Page 2 of 4 Patient/Resident Name: ______________________________________________ Date: __________________________ ACTIVITIES OF DAILY LIVING (ADL’s) Activity Restrictions: No Yes (describe):___________________________________________________________________ Dependent on Medical Equipment: No Yes (describe):________________________________________________________ Does the resident need the assistance of another person to perform the following? Ambulate: No Yes Intermittent Continual Transfer: No Yes Intermittent Continual Feeding: No Yes Intermittent Continual Manage Medical Equipment: No Yes Intermittent Continual ADDITIONAL SERVICES: None (List all that are needed. Attach additional sheet if necessary) Reason Reason Physical Therapy ______________________________ Speech Therapy _____________________________________ Occupational Therapy ________________________ Other (Specify) ___________________________________ Home Care: Nursing PCA HHA Other (describe) ________________________________________________ LABORATORY SERVICES: None L ab Test Reason/Frequency Lab Test Reason/Frequency ________________ _______________________________ ________________ _________________________ __________________ __________________________________ _________________ ____________________________ COGNITIVE IMPAIRMENT/MEMORY LOSS Based on your examination and/or information received from caregivers, do you recommend the patient be screened and/or tested for dementia or another cognitive impairment? (If yes, indicate who will perform screening/testing below) No Yes (describe) ________________________________________________________________________ If yes, testing to be performed by:___________________________________________________________________ MENTAL HEALTH ASSESSMENT Does the patient have a history of or a current mental disability? Yes No Has the patient ever been hospitalized for a mental health condition? Yes No If Yes, describe: __________________________________________________________________________________________ Based on your examination, would you recommend the patient seek a mental health evaluation? (If yes, provide referral) No Yes Describe: ________________________________________________________________________ Comments: ____________________________________________________________________________________________ _______________________________________________________________________________________________________ New York State Department of Health ASSISTED LIVING RESIDENCE Division of Home and Community Based Services MEDICAL EVALUATION DOH 3122 (Dev. 03/08) Rev. 1/09 Page 3 of 4 Patient/Resident Name: ________________________________________________ Date: ____________________________ Pursuant to NYCRR Title 18 487.7(f)(2), the patient is NOT capable of self-administration of medication if he/she needs assistance to properly carry out ONE OR MORE of the following tasks: Correctly read the label on a medication container Correctly follow instructions as the route, time dosage and frequency Correctly ingest, inject or apply the medication Measure or prepare medications, including mixing, shaking and filling syringes Open the container Safely store the medication Correctly interpret the label MEDICATIONS: (List all prescription, OTC medications, supplements and vitamins. Attach additional sheet if necessary.) Medication Dosage Type Frequency Route Diagnosis Prescriber (name of MD/NP) Needs assistance with administration Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No New York State Department of Health ASSISTED LIVING RESIDENCE Division of Home and Community Based Services MEDICAL EVALUATION DOH 3122 (Dev. 03/08) Rev. 1/09 Page 4 of 4 Patient/Resident Name: ________________________________________________ Date: ________________________ Pertinent medical/mental findings requiring follow-up by facility (e.g. skin conditions/acute or chronic pain issues) or any additional recommendations for follow-up:__________________________________ ________________________________________________________________________________________ PHYSICIAN CERTIFICATION I certify that I have physically examined this patient and have accurately described the individual’s medical condition, medication regimen and need for skilled and/or personal care services. Based on this examination and my knowledge of the patient, this individual (see Statement of Purpose): IS IS NOT mentally suited for care in an Adult Home or Enriched Housing Program. IS IS NOT medically suited for care in an Adult Home or Enriched Housing Program. IS IS NOT in need of continual acute or long term medical or nursing care or supervision which would require placement in a hospital or nursing home. IS IS NOT in need of 24-hour skilled nursing care. LEVEL OF CARE RECOMMENDATION: (see Statement of Purpose) Adult Home/Enriched Housing Program/Assisted Living Residence Enhanced ALR Special Needs ALR Name/Title of individual completing form:_____________________________________________ Date:________ Physician Signature: ________________________________________________ Date _______________________ STATEMENT OF PURPOSE Adult Homes (AH), Enriched Housing Programs (EHP), Residences for Adults (RFA), Assisted Living Residences (ALR), Enhanced Assisted Living Residences (EALR) and Special Needs Assisted Living Residences (SNALR) provide 24-hour residential care for dependent adults. They are not medical facilities. Persons in need of constant medical care and medical supervision should not be admitted or retained in these settings because the facility lacks the staff and expertise to provide needed services. Persons who, by reason of age and/or physical and/or mental limitations are in need of assistance with activities of daily living, can be cared for in adult residential care settings listed above. ALRs with certification to provide: Enhanced ALR care may serve people who need chronic assistance from another person with ambulation, transfer, ascending / descending stairs; are dependent on medical equipment, have intermittent nursing needs (less than 24 hours a day); or have chronic, unmanaged urinary or bowel incontinence. Special Needs ALR care may serve people who have a need for a secured environment and/or highly specialized services due to advanced dementia or other special need.