"Child and Adult Health and Functional Assessment Form" - Hawaii

Child and Adult Health and Functional Assessment Form is a legal document that was released by the Hawaii Department of Health - a government authority operating within Hawaii.

Form Details:

  • Released on March 1, 2017;
  • The latest edition currently provided by the Hawaii Department of Health;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Hawaii Department of Health.

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Download "Child and Adult Health and Functional Assessment Form" - Hawaii

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STATE OF HAWAII
HEALTH AND FUNCTIONAL ASSESSMENT
CHILD AND ADULT
Child
Adult
Health Plan
Long Term Services and Supports (LTSS)
Special Health Care Needs (SHCN)
At Risk
SECTION A. ADMINISTRATIVE INFORMATION
A1. Member
a. Member Name
b. Date of Birth c. Medicaid ID#
  /  /    
Last
First
MI
A2. Assessment
a. Reason for Assessment
b. Assessment Reference Information
1. Initial
1. Date:   /  /    
2. Reassessment
2. Time:   :  
AM
PM
3. Annual
3. Assessment Location:
4. Change of Condition/Status:
4. Member’s Resident Address:
5. Identify any safety issues that a SC may encounter
during the assessment.
c. Assessor (Primary)
e. Additional Health Plan Insurance
1. Assessor Name:
1. Health Plan Name:
2. Title:
2. Subscriber Name:
3. Subscriber Number:
d. Assessor (Consult)
4. Are you a veteran?
Yes
No
1. Assessor Name:
5. Are you receiving any veteran benefits?
Yes
No
2. Title:
Identify:
f. Medicare
g. Other Individual(s) Participating in the Assessment
1. Medicare
Yes
No
1. Is there a legal guardian, or representative assisting in the
ID#
assessment?
Yes
No
2. Other individuals present?
Yes
No
2. Medicare Advantage
Yes
No
3. Name of Participants
Plan Name:
ID#
Name
Relationship
Purpose
h. Comments:
A3. Legal Information
No Change from Previous Assessment
a. Legal Responsibility(ies)
Health Plan Copy
b. Advance Directives
1. Self
1. Do you have an Advance Directive?
2. Legal Guardian
Yes
No
Yes
No
2. If yes, do you have a copy of the Advance
Name:
Directive?
3. Authorized Representative
Yes
No
ADULT ASSESSMENT TOOL (REV. 03/17)
DO NOT MODIFY FORM
Page 1 of 21
STATE OF HAWAII
HEALTH AND FUNCTIONAL ASSESSMENT
CHILD AND ADULT
Child
Adult
Health Plan
Long Term Services and Supports (LTSS)
Special Health Care Needs (SHCN)
At Risk
SECTION A. ADMINISTRATIVE INFORMATION
A1. Member
a. Member Name
b. Date of Birth c. Medicaid ID#
  /  /    
Last
First
MI
A2. Assessment
a. Reason for Assessment
b. Assessment Reference Information
1. Initial
1. Date:   /  /    
2. Reassessment
2. Time:   :  
AM
PM
3. Annual
3. Assessment Location:
4. Change of Condition/Status:
4. Member’s Resident Address:
5. Identify any safety issues that a SC may encounter
during the assessment.
c. Assessor (Primary)
e. Additional Health Plan Insurance
1. Assessor Name:
1. Health Plan Name:
2. Title:
2. Subscriber Name:
3. Subscriber Number:
d. Assessor (Consult)
4. Are you a veteran?
Yes
No
1. Assessor Name:
5. Are you receiving any veteran benefits?
Yes
No
2. Title:
Identify:
f. Medicare
g. Other Individual(s) Participating in the Assessment
1. Medicare
Yes
No
1. Is there a legal guardian, or representative assisting in the
ID#
assessment?
Yes
No
2. Other individuals present?
Yes
No
2. Medicare Advantage
Yes
No
3. Name of Participants
Plan Name:
ID#
Name
Relationship
Purpose
h. Comments:
A3. Legal Information
No Change from Previous Assessment
a. Legal Responsibility(ies)
Health Plan Copy
b. Advance Directives
1. Self
1. Do you have an Advance Directive?
2. Legal Guardian
Yes
No
Yes
No
2. If yes, do you have a copy of the Advance
Name:
Directive?
3. Authorized Representative
Yes
No
ADULT ASSESSMENT TOOL (REV. 03/17)
DO NOT MODIFY FORM
Page 1 of 21
STATE OF HAWAII
HEALTH AND FUNCTIONAL ASSESSMENT
CHILD AND ADULT
Child
Adult
Health Plan
Long Term Services and Supports (LTSS)
Special Health Care Needs (SHCN)
At Risk
Name:
Yes
No
4. Healthcare Power of Attorney
Yes
No
3. If no, would you like more information on Advance
Name:
Directives?
5. Family Educational Rights and Privacy Act (FERPA)
Yes
No
Yes
No
4. Health Plan obtained copy for records?
Yes
No
6. Other:
5. Do you have a Physician Orders for Life-Sustaining
Name:
Treatment (POLST)?
Yes
No
7. Identify parents or adults who are NOT allowed
6. Location of POLST:
information on the member, only if identified on a
legal document. Name:
c. Emergency Contact(s)
Relationship
Name
Address
Phone number
Email address
to member
Primary
Secondary
d. Emergency Plan (Complete this question for HCBS Community)
1. Is your Individualized Emergency Back-up Plan Form completed?
Yes
No
2. If yes, where is it located?
3. If No, complete ATTACHMENTS for QI Individualized Back-up document and provide a copy to member.
e. Comments – Identify any risk factors:
SECTION B. DEMOGRAPHIC INFORMATION
B1. Demographics
No Change from Previous Assessment
a. Gender
b. Relationship Status
1. Male
1. Single
4. Separated
2. Female
2. Married
5. Widowed
3. Preferred
3. Divorced
6. Other:
Gender Identity:
ADULT ASSESSMENT TOOL (REV. 03/17)
DO NOT MODIFY FORM
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STATE OF HAWAII
HEALTH AND FUNCTIONAL ASSESSMENT
CHILD AND ADULT
Child
Adult
Health Plan
Long Term Services and Supports (LTSS)
Special Health Care Needs (SHCN)
At Risk
c. Ethnicity
1. African American
2. American Indian or Alaska Native
3. Asian
i. Cambodian
iv. Indian
vii. Laotian
ii. Chinese
v. Japanese
viii. Vietnamese
iii. Filipino
vi. Korean
ix. Other
4. Caucasian
5. Hispanic or Latino
6. Native Hawaiian or other Pacific Islander
i. Federated States of Micronesia
v. Samoan
ii. Native Hawaiian
vi. Tongan
iii. Palauan
vii. Other
iv. Marshallese
7. Other:
B2. Communication
No Change from Previous Assessment
a. Primary Means of Communication
1. Verbal
3. Written
5. Other:
2. Non Verbal
4. American Sign Language
b. Primary Spoken Language
c. Interpretation
1. English
11. Laotian
1. Do you need an interpreter?
2. Chinese (Cantonese)
12. Marshallese
Yes
No
3. Chinese (Mandarin)
13. Palauan
4. Chuukese
14. Samoan
5. French
15. Spanish
6. German
16. Tagalog
7. Hawaiian
17. Tongan
8. Ilocano
18. Vietnamese
9. Japanese
19. Visayan
10. Korean
20. Other:
d. Primary Written Language
e. Translation
1. English
12. Laotian
1. Do you need a translation?
2. Braille
13. Large Format
Yes
No
3. Chinese (Cantonese)
14. Marshallese
4. Chinese (Mandarin)
15. Palauan
5. Chuukese
16. Samoan
6. French
17. Spanish
7. German
18. Tagalog
8. Hawaiian
19. Tongan
9. Ilocano
20. Vietnam
10. Japanese
21. Visayan
11. Korean
22. Other:     
f. Other Assistive Communication Device(s):
None
g. Comments:
B3. Residence and Living Arrangements
No Change from Previous Assessment
ADULT ASSESSMENT TOOL (REV. 03/17)
DO NOT MODIFY FORM
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STATE OF HAWAII
HEALTH AND FUNCTIONAL ASSESSMENT
CHILD AND ADULT
Child
Adult
Health Plan
Long Term Services and Supports (LTSS)
Special Health Care Needs (SHCN)
At Risk
a. Residence
1. Own Private house/apartment
8. DD Adult Foster Home
2. Rent Private house/apartment/room
9. Community Care Foster Family Home (CCFFH)
3. Houseless (with or without shelter)
10. Nursing Facility (NF)
4. Assisted Living Facility (ALF)
11. Rehabilitation hospital/unit
5. Adult Residential Care Home (ARCH)
12. Psychiatric hospital/unit
6. Expanded Adult Residential Care Home (E-ARCH)
13. Acute care hospital
7. Foster Home (Children)
14. Other:
b. Living Arrangement
1. Alone
4. With child (not spouse/partner)
7. With other relative(s)
2. With spouse/partner only
5. With parent(s)/guardian(s)
8. With non-relative(s)
3. With spouse/partner and other(s)
6. With sibling(s)
9. Other:
c. Type of Subsidized Housing
i. Hawaiian Homestead
ii. Section 8
iii. Public Housing
iv. Other:
d. Comments:
SECTION C. MEDICAL INFORMATION
C1. Disease Diagnosis(es)
No Change from Previous Assessment
a. Disease Diagnosis(es)
List Disease Diagnosis(es)
ICD-10 Code
Date of Onset
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
  /  /    
Unknown
b. Comments – Identify any risk factors:
C2. Transplant
No Change from Previous Assessment
a. Transplant
1. Have you had a transplant?
Yes
No
2. What type of transplant?
ADULT ASSESSMENT TOOL (REV. 03/17)
DO NOT MODIFY FORM
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STATE OF HAWAII
HEALTH AND FUNCTIONAL ASSESSMENT
CHILD AND ADULT
Child
Adult
Health Plan
Long Term Services and Supports (LTSS)
Special Health Care Needs (SHCN)
At Risk
3. Is member compliant with transplant related medication and provider follow-up?
Yes
No
4. If not, document action plan.
b. Comments – Identify any risk factors:
C3. Medications (Prescribed and OTC)
No Change from Previous Assessment
1. Are you taking any medications, including vitamins, supplements, herbal or OTC medications?
Yes
No
2. If Yes, attach a current Medication list and/or complete the Medication Attachment Form. Attach to assessment
and service plan.
3. Allergies:
Yes
No Specify:
C4. Treatments and Therapy(ies)
No Change from Previous Assessment
NA
Provider/
Treatment/Therapy
Prescribing Provider
Frequency
Comments/Needs
Agency
C5. Medical Equipment and Supplies
No Change from Previous Assessment
NA
Medical
Type/Description
Indicate
Vendor and Phone
Equipment and
Prescribing Provider
Comments/Needs
/Amount
Rent or Own
Number
Supplies
Rent
Own
Rent
Own
Rent
Own
Rent
Own
Rent
Own
C6. Physician(s) and Provider(s)
No Change from Previous Assessment
Phone
Physician(s)/Provider(s) Name
Specialty
Address
Fax Number
Number
C7. Utilization of Hospital, Emergency Room, and Physician Services
No Change from Previous Assessment
1. How many times did you go to the hospital within the past
0
1-2
3 or more
twelve months?
2. How many times did you go to the emergency room within the
0
1-2
3 or more
past six months?
Services
Date
Reason
ADULT ASSESSMENT TOOL (REV. 03/17)
DO NOT MODIFY FORM
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