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 / 20ADDRESSPERSON IS CURRENTLYLiving IndependentlyLiving with ChildrenHospitalizedOtherEmailCOMMENTSTELEPHONE or MOBILEDOB.SEXMaleFemaleMARITAL STATUSSingleMarriedDivorced/SeparatedWidow(er)Resident able to participate in providing above information?YESNOResident bed-bound or similarly immobilized?YESNOHas the resident exhibited behaviors that present a reasonable likelihood of serious harm to self or others?YESNOResident requires a physical restraint?YESNOResident uses a medication as a chemical restraint?YESNOResident has a condition that requires skilled nursing services? If yes, please list:YESNOResident requires more than one person to simultaneously physically assist with any activities of daily living as bathing and/or transferring?YESNOTO 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 NAMEDATERESIDENT NAMERESPONDENT NAMEPERSONAL CARE – Grooming/BathingBathingPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTDental /Mouth CarePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTHair CarePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTShavingPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTToe / Fingernail carePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENT Personal Care – Toileting Bladder/Blowel ControlYESNOSpecial Equipment Required (List)Catheter/OstomyYESNODietaryEats Meals DailyPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTMeals PreparationPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTChewing/SwallowingPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTRecent Weight Loss/GainYESNOUses Feeding Tubes/Devices Calculated Diet PrescribedYESNOSpecial Diet FollwedYESNOMobilityAmbulatory – Able to Get AroundPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTTransfer To/From BedPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTTransfer To/From ChairPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTTransfer To/From WheelchairPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTSafety evacuates the facility with minimal assistanceYESNOHousekeepingCleans Bedroom, Bathroom, KitchenPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTLaundryPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTMake/Change BedsPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTEmpty TrashPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTBEHAVIOR/MENTAL CONDITIONOrientation to Date, Day, and PlacePERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTWanders or confusionPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTMemory/RecallPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTJudgementPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTFollows InstructionsPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTSociabilityPERFORMS INDEPENDTLYSOME ASSISTANCETOTALLY DEPENDENTSad or AnxiousYESNOMood Socially Inappropriate/Disruptive BehaviorYESNODiagnosed or Treatment History for Mental Illness or Developmental DisabilityYESNOTRANSPORTATION Can drive selfYESNOCan leave the facility with out assistanceYESNOMEDICAL NEEDS/SUPPORTS/MONITORINGRESIDENT CANSelf AdministerNeeds AssistanceTotally dependentHealth Problems (Check All That Current Apply)AnemiaPrescription MedsDosagePhysician/PharmacyArthritis and other joint limitations or injuriesPrescription MedsDosagePhysician/PharmacyBowel/bladder problemsPrescription MedsDosagePhysician/PharmacyCancer, Leukemia or tumorPrescription MedsDosagePhysician/PharmacyDementia (OBS, Alzheimer's, Huntington's, Pick's)Prescription MedsDosagePhysician/PharmacyDiabetesPrescription MedsDosagePhysician/PharmacyDigestive disorders (ulcers, diverticulosis)Prescription MedsDosagePhysician/PharmacyEdemaPrescription MedsDosagePhysician/PharmacyEffects Of stroke (CVA, TIA, memory loss)Prescription MedsDosagePhysician/PharmacyEffects Of osteoporosis or fracturesPrescription MedsDosagePhysician/PharmacyHardening of arteries (ASHD, poor circulation)Prescription MedsDosagePhysician/PharmacyHearing impairment (H.O.H., deafness)Prescription MedsDosagePhysician/PharmacyHeart trouble (angina, CHF, MI)Prescription MedsDosagePhysician/PharmacyHypertensionPrescription MedsDosagePhysician/PharmacyRespiratory problems (asthma, emphysema, COPD)Prescription MedsDosagePhysician/PharmacySkin problems (decubitus ulcer, lesions, rashes)yesSurgery with residual effects (drainage, amputation, paralysis, pain, fatigue)yesTremors (Parkinson's)yesVisual impairment (cataracts, glaucoma, blindness)yesOTHER (PLEASE LIST:)Register
