Pre-Screening And Assessment For Admission To Aastha Assisted Living Facility Pre-Screening And Assessment For Admission To Aastha Assisted Living Facility NAME (FIRST, MIDDLE, LAST) * Aadhaar Card Number *0 / 20 ADDRESS PERSON IS CURRENTLYLiving IndependentlyLiving with ChildrenHospitalizedOther Email COMMENTS TELEPHONE or MOBILE DOB. SEXMaleFemale MARITAL STATUSSingleMarriedDivorced/SeparatedWidow(er) Resident able to participate in providing above information?YESNO Resident bed-bound or similarly immobilized?YESNO Has the resident exhibited behaviors that present a reasonable likelihood of serious harm to self or others?YESNO Resident requires a physical restraint?YESNO Resident uses a medication as a chemical restraint?YESNO Resident has a condition that requires skilled nursing services? If yes, please list:YESNO Resident requires more than one person to simultaneously physically assist with any activities of daily living as bathing and/or transferring?YESNO TO BE DETERMINED BY PERSON DOING RESIDENT ASSESSMENTYes Resident meets criteria for admission to Assisted Living Aastha Pvt. LtdYes Resident meets criteria for admission to Assisted Living Aastha Pvt. Ltd. Facility which provides services to residents with a physical, cognitive or other impairments .No Resident is not eligible for admission to an Assisted Living Aastha Pvt. Ltd. INTERVIEWER'S NAME DATE RESIDENT NAME RESPONDENT NAME PERSONAL CARE – Grooming/Bathing BathingPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Dental /Mouth CarePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Hair CarePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT ShavingPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Toe / Fingernail carePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Personal Care – Toileting Bladder/Blowel ControlYESNO Special Equipment Required (List) Catheter/OstomyYESNO Dietary Eats Meals DailyPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Meals PreparationPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Chewing/SwallowingPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Recent Weight Loss/GainYESNO Uses Feeding Tubes/Devices Calculated Diet PrescribedYESNO Special Diet FollwedYESNO Mobility Ambulatory – Able to Get AroundPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Transfer To/From BedPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Transfer To/From ChairPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Transfer To/From WheelchairPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Safety evacuates the facility with minimal assistanceYESNO Housekeeping Cleans Bedroom, Bathroom, KitchenPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT LaundryPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Make/Change BedsPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Empty TrashPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT BEHAVIOR/MENTAL CONDITION Orientation to Date, Day, and PlacePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Wanders or confusionPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Memory/RecallPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT JudgementPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Follows InstructionsPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT SociabilityPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Sad or AnxiousYESNO Mood Socially Inappropriate/Disruptive BehaviorYESNO Diagnosed or Treatment History for Mental Illness or Developmental DisabilityYESNO TRANSPORTATION Can drive selfYESNO Can leave the facility with out assistanceYESNO MEDICAL NEEDS/SUPPORTS/MONITORING RESIDENT CANSelf AdministerNeeds AssistanceTotally dependent Health Problems (Check All That Current Apply) AnemiaPrescription MedsDosagePhysician/Pharmacy Arthritis and other joint limitations or injuriesPrescription MedsDosagePhysician/Pharmacy Bowel/bladder problemsPrescription MedsDosagePhysician/Pharmacy Cancer, Leukemia or tumorPrescription MedsDosagePhysician/Pharmacy Dementia (OBS, Alzheimer's, Huntington's, Pick's)Prescription MedsDosagePhysician/Pharmacy DiabetesPrescription MedsDosagePhysician/Pharmacy Digestive disorders (ulcers, diverticulosis)Prescription MedsDosagePhysician/Pharmacy EdemaPrescription MedsDosagePhysician/Pharmacy Effects Of stroke (CVA, TIA, memory loss)Prescription MedsDosagePhysician/Pharmacy Effects Of osteoporosis or fracturesPrescription MedsDosagePhysician/Pharmacy Hardening of arteries (ASHD, poor circulation)Prescription MedsDosagePhysician/Pharmacy Hearing impairment (H.O.H., deafness)Prescription MedsDosagePhysician/Pharmacy Heart trouble (angina, CHF, MI)Prescription MedsDosagePhysician/Pharmacy HypertensionPrescription MedsDosagePhysician/Pharmacy Respiratory problems (asthma, emphysema, COPD)Prescription MedsDosagePhysician/Pharmacy Skin problems (decubitus ulcer, lesions, rashes)yes Surgery with residual effects (drainage, amputation, paralysis, pain, fatigue)yes Tremors (Parkinson's)yes Visual impairment (cataracts, glaucoma, blindness)yes OTHER (PLEASE LIST:) Register
