DOEA Form 701B "Comprehensive Assessment" - Florida

Form 701B is a Florida Department of Elder Affairs form also known as the "Comprehensive Assessment". The latest edition of the form was released in April 1, 2013 and is available for digital filing.

Download a PDF version of the Form 701B down below or find it on Florida Department of Elder Affairs Forms website.

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Download DOEA Form 701B "Comprehensive Assessment" - Florida

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Florida Department of Elder Affairs
701B Comprehensive Assessment
Rule: 58-A-1.010, F.A.C.
Provider
Provider ID:
Assessor/CM ID:
Assessor/Case
Manager (CM) Name:
Signature:
A. DEMOGRAPHIC SECTION
1. ASSESSOR/CM: What is the purpose of this assessment?
Initial
Annual
Health
Living situation
Caregiver
Environment
Income
2. Social Security number:
3. Name: a. First:
b. Middle initial:
c. Last:
4. Medicaid number:
5. Phone number:
6. Date of birth (mm/dd/yyyy):
7. Sex:
Male
Female
8. Race (Mark all that apply):
White
Black/African American
Asian
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
Other
9. Ethnicity:
Hispanic/Latino
Other
10. Primary language:
English
Spanish
Other:
11. Does client have limited ability reading, writing, speaking, or understanding English?
No
Yes
12. Marital status:
Married
Partnered
Single
Separated
Divorced
Widowed
13. ASSESSOR/CM: Current Physical Location Address (If type is a facility, enter facility name.)
a. Street:
b. City:
c. ZIP code:
d. Type:
Private residence
Assisted living facility (ALF)
Nursing facility
Hospital
Adult day care
Other
e. Name:
14. Home Address (If different from current physical location)
a. Street:
b. City:
c. ZIP code:
15. Is client’s home address public housing?
No
Yes
16. Mailing Address (If different from current physical location)
a. Street:
b. City:
c. State:
d. ZIP code:
1 DOEA 701B, April 2013
Florida Department of Elder Affairs
701B Comprehensive Assessment
Rule: 58-A-1.010, F.A.C.
Provider
Provider ID:
Assessor/CM ID:
Assessor/Case
Manager (CM) Name:
Signature:
A. DEMOGRAPHIC SECTION
1. ASSESSOR/CM: What is the purpose of this assessment?
Initial
Annual
Health
Living situation
Caregiver
Environment
Income
2. Social Security number:
3. Name: a. First:
b. Middle initial:
c. Last:
4. Medicaid number:
5. Phone number:
6. Date of birth (mm/dd/yyyy):
7. Sex:
Male
Female
8. Race (Mark all that apply):
White
Black/African American
Asian
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
Other
9. Ethnicity:
Hispanic/Latino
Other
10. Primary language:
English
Spanish
Other:
11. Does client have limited ability reading, writing, speaking, or understanding English?
No
Yes
12. Marital status:
Married
Partnered
Single
Separated
Divorced
Widowed
13. ASSESSOR/CM: Current Physical Location Address (If type is a facility, enter facility name.)
a. Street:
b. City:
c. ZIP code:
d. Type:
Private residence
Assisted living facility (ALF)
Nursing facility
Hospital
Adult day care
Other
e. Name:
14. Home Address (If different from current physical location)
a. Street:
b. City:
c. ZIP code:
15. Is client’s home address public housing?
No
Yes
16. Mailing Address (If different from current physical location)
a. Street:
b. City:
c. State:
d. ZIP code:
1 DOEA 701B, April 2013
Florida Department of Elder Affairs: 701B Comprehensive Assessment
A. DEMOGRAPHIC SECTION, CONTINUED
17. ASSESSOR/CM: Assessment date: (mm/dd/yyyy)
18. ASSESSOR/CM: Assessment site:
Home
ALF
Nursing facility
Hospital
Adult day care
Other
19. ASSESSOR/CM: Referral date:
(mm/dd/yyyy)
20. ASSESSOR/CM: Referral source:
Self/Family
Nursing facility
Case management agency
CARES
Aging out
Hospital
Department of Children and Families
Other
APS: Select level of APS risk:
High
Intermediate
Low
21. ASSESSOR/CM: Transitioning out of a nursing facility?
No
Yes
22. ASSESSOR/CM: Imminent risk of nursing home placement?
No
Yes
23. Do you need outside assistance to evacuate?
No
Yes
24. Are you enrolled on a special needs registry?
No
Yes
25. Is there a primary caregiver?
No
Yes
26. Living situation:
With primary caregiver
With other caregiver
With other
Alone
27. Individual monthly income:
Refused
$
28. Couple monthly income:
Refused
N/A
$
29. Estimated total individual assets: $
$0 to $2,000
$2,001 to $5,000
$5,001 or more
Refused
30. Estimated total couple assets:
$
$0 to $3,000
$3,001 to $6,000
$6,001 or more
Refused
N/A
31. Are you receiving S/NAP (food stamps)?
No
Yes
32. Do you need other assistance for food?
No
Yes
33. ASSESSOR/CM: Is someone besides the client providing answers to questions?
No (Skip to 34)
Yes
a. Name:
b. Relationship:
34. Besides your own children, how many children under age 19 do you live with and provide care for?
(if zero, skip to 35)
#
a. How many are grandchildren?
#
Name(s):
b. How many are other related children?
#
Name(s):
c. How many are other non-related children?
#
Name(s):
35. How many disabled adults age 19 to 59 do you live with and provide care for? (if zero, skip to 36)
#
a. How many are grandchildren?
#
Name(s):
b. How many are other relatives?
#
Name(s):
c. How many are other non-relatives?
#
Name(s):
Notes & Summary:
2 DOEA 701B, April 2013
Florida Department of Elder Affairs: 701B Comprehensive Assessment
B. MEMORY SECTION
36. Has a doctor or other health care professional told you that you suffer from memory loss, cognitive
impairment, any type of dementia, or Alzheimer’s disease?
No
Yes
37. ASSESSOR/CM: If the client is not answering questions, skip to Question 47 and check:
38. “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.” ASSESSOR/CM: Select the number of words correctly repeated after the first attempt:
Sock
Blue
Bed
Total number of correct words:
None
One
Two
Three
“Thank you. I will ask you to repeat these to me again later.”
39. Please tell me what year it is:
Correct
Missed by one year
Missed by two to five years
Missed by five or more years
No answer
40. Please tell me what month it is:
Correct
Missed by one month
Missed by two to five months
Missed by five or more months
No answer
41. Please tell me what day (of the week) it is:
Correct
Incorrect
No answer
42. “Let’s go back to an earlier question. What were those words I asked you to repeat back to me?”
Sock
Blue
Bed
43. ASSESSOR/CM: Number of words correctly recalled without prompting:
None
One
Two
Three
44. Have any friends or family members expressed concern about your memory?
No
Yes
45. Have you become concerned about your memory or had problems
No (Skip to 47)
Yes
remembering important things?
46. How often do you have problems remembering things?
Always
Often
Sometimes
Rarely
Don’t know
47. ASSESSOR/CM: In your opinion, are cognitive problems present?
No
Yes
Don’t know
Notes & Summary:
3 DOEA 701B, April 2013
Florida Department of Elder Affairs: 701B Comprehensive Assessment
C. GENERAL HEALTH, SENSORY & COMMUNICATION SECTION
48. How would you rate your overall health at this time?
Excellent
Very Good
Good
Fair
Poor
49. Compared to a year ago, how would you rate your health?
Much better
Better
About the same
Worse
Much worse
50. How often do you change or limit your activities out of fear of falling?
Never
Occasionally
Often
All of the time
51. How many times have you fallen in the last six months?
#
52. How often are there things you want to do but cannot because of physical problems?
Never
Occasionally
Often
All of the time
53. When you need medical care, how often do you get it?
Always
Most of the time
Rarely
Only in an emergency
Never
54. When you need transportation to medical care, how often do you get it?
Always
Most of the time
Rarely
Only in an emergency
Never
55. Do you drive a car or other motor vehicle?
No
Yes
56. How often do finances/insurance allow you to obtain health care and medications when you need them?
Always
Most of the time
Rarely
Only in an emergency
Never
57. Have you visited the emergency room (ER) or been admitted to the hospital within the last year?
Yes: How many times? ER#
No
Hospital #
58. In the last year were you in a nursing or rehabilitation facility?
No
Yes
59. Are you usually able to climb two or three stair steps?
No
Yes
Don’t know
60. ASSESSOR/CM: Are there any stairs within the dwelling or leading into/out of the dwelling?
No
Yes
61. Are you usually able to carry a full glass of water across a room without spilling it?
No
Yes
Don
t know
62. Has a doctor told you that you currently have vision problems?
No
Yes
Blind (If blind, skip to 63)
a. Have you had an eye exam in the past year?
No
Yes
b. Do you bump into objects (people, doorways) because you don’t see them?
No
Yes
c. Is your vision getting worse than it was last year?
No
Slightly worse
Much worse
In one eye
63. Has a doctor told you that you currently have hearing problems?
No
Yes
Deaf (If deaf, skip to 64)
a. Have you had a hearing exam in the past year?
No
Yes
b. Can you understand words clearly over the telephone?
No
Yes
c. Is your hearing worse than it was last year?
No
In one ear
Slightly worse
Much worse
64. ASSESSOR/CM: Does client rely on writing, gestures, or signs to communicate?
No
Yes
65. ASSESSOR/CM: Are the client’s words formed properly, not slurred or clipped?
No
Yes
66. ASSESSOR/CM: Are any sensory aids or assistive devices currently used?
No
Yes
If yes, please list the type(s) used:
67. ASSESSOR/CM: Is there an unmet need for a sensory aid or assistive device?
No
Yes
If yes, please list the type(s) needed:
4 DOEA 701B, April 2013
Florida Department of Elder Affairs: 701B Comprehensive Assessment
D. ACTIVITIES OF DAILY LIVING SECTION
68. How much assistance do you need with the following tasks?
No
Uses
Needs
Needs
Needs total
Task
assistance
assistive
supervision
assistance (but
assistance
needed
device
or prompt
not total help)
(cannot do at all)
a. Bathing
b. Dressing
c. Eating
d. Using the bathroom
e. Transferring
f.
Walking/Mobility
69. ASSESSOR/CM: Is there an unmet need for an ADL assistive device?
No
Yes
If yes, type(s) needed:
70. How much assistance do you have with the following tasks?
Has
No
assistance
Task
assistance
Always has
most of the
Rarely has
Never has
needed
assistance
time
assistance
assistance
a. Bathing
b. Dressing
c. Eating
d. Using the bathroom
e. Transferring
f.
Walking/Mobility
Notes & Summary:
5 DOEA 701B, April 2013
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