"Adult Day Center Intake Screening Form" - Pennsylvania

Adult Day Center Intake Screening Form is a legal document that was released by the Pennsylvania Department of Aging - a government authority operating within Pennsylvania.

Form Details:

  • Released on September 24, 2014;
  • The latest edition currently provided by the Pennsylvania Department of Aging;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • 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 Pennsylvania Department of Aging.

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Download "Adult Day Center Intake Screening Form" - Pennsylvania

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Adult Day Center Intake Screening
Date_____________________
Part I: Personal Information
Financial Responsible Party
Name:
Name:
Nickname:
Address, Town, and Zip Code:
Address, Town, and Zip Code:
Relationship:
Phone:
Phone:
Height:
Cell:
Weight:
Eye Color:
Emergency Contact #1
Hair Color:
Name:
Sex:
_______M
______F
Address, Town, and Zip Code:
Birthdate:
Age:
SS# xxx-xx-
Relationship:
Marital Status:
Phone:
Spouse’s Name:
Cell:
Identifying Marks:
Emergency Contact #2
Responsible Party
Name:
Name:
Address, Town, and Zip Code:
Address, Town, and Zip Code:
Relationship:
Relationship:
Phone:
Phone:
Cell:
Cell:
Part II: Legal Status
Is there any one person authorized to make decisions under a power of attorney or a legal guardian?
If yes, who/relationship:
Do you have a living will or advanced directive?
If yes for either question, we need a copy for our file.
PART III: Referral
How did you hear about the Adult Day Center?
Reason for wanting to attend the Adult Day Center?
If you are determined eligible, how many days per week are you interested in coming to the center?
Which Days?
Sun Mon Tue Wed Thurs Fri Sat
PART IV: Living Arrangements and Transportation
Living Arrangements: Spouse_____ Child _____ Other, specify ________________
Type of Dwelling: House _____ Apartment _____ Other, specify ___________________
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09/24/2014
Adult Day Center Intake Screening
Date_____________________
Part I: Personal Information
Financial Responsible Party
Name:
Name:
Nickname:
Address, Town, and Zip Code:
Address, Town, and Zip Code:
Relationship:
Phone:
Phone:
Height:
Cell:
Weight:
Eye Color:
Emergency Contact #1
Hair Color:
Name:
Sex:
_______M
______F
Address, Town, and Zip Code:
Birthdate:
Age:
SS# xxx-xx-
Relationship:
Marital Status:
Phone:
Spouse’s Name:
Cell:
Identifying Marks:
Emergency Contact #2
Responsible Party
Name:
Name:
Address, Town, and Zip Code:
Address, Town, and Zip Code:
Relationship:
Relationship:
Phone:
Phone:
Cell:
Cell:
Part II: Legal Status
Is there any one person authorized to make decisions under a power of attorney or a legal guardian?
If yes, who/relationship:
Do you have a living will or advanced directive?
If yes for either question, we need a copy for our file.
PART III: Referral
How did you hear about the Adult Day Center?
Reason for wanting to attend the Adult Day Center?
If you are determined eligible, how many days per week are you interested in coming to the center?
Which Days?
Sun Mon Tue Wed Thurs Fri Sat
PART IV: Living Arrangements and Transportation
Living Arrangements: Spouse_____ Child _____ Other, specify ________________
Type of Dwelling: House _____ Apartment _____ Other, specify ___________________
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09/24/2014
Adult Day Center Intake Screening
Circle: Lives with someone
Lives alone
Present Address:
What transportation you will use to get to and from the Center?
Does the applicant carry a house key? _____ If yes, can applicant be left at home alone? ______
PART V: Family and Social History
Birthplace:
Father’s Name:
Mother’s Name:
Names of living brother and/or sisters:
Names of deceased brothers and/or sisters:
Names of living children:
Names of deceased children:
What was the highest grade in school you completed?
Are you a veteran, spouse of a veteran, parent of a veteran? (Circle one) What branch? _____________
What was/is your main occupation?
What was your worst job?
Circle activities of potential interest.
Arts and Crafts
Bingo
Cards
Physical Games
Music/Choir
Table Games
Exercise
Pet Therapy
Socializing
Plant Care
Read Newspaper or Magazine
Other: ________________
Sensory/Mental Stimulation
Bible Study
Is applicant comfortable being in the company of non-family members? __________________________
What is one of your best skills?
PART VI: Medical Information and Health History
Diagnosis:
Primary Doctor:
Address, Town, and Zip Code:
Phone:
How would you rate your own health?
Current Medical Problems:
Past Medical Problems:
Date of last hospitalization:
Where:
Reason:
Do you have diabetes?
How is it controlled? Oral medications? Injection? Diet?
Do you have seizures? _____ If yes, explain: ________________________________________________
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Adult Day Center Intake Screening
Are you allergic to any medications? _____ If yes, explain: ____________________________________
Are you allergic to any environmental allergens? _____ If yes, explain: ___________________________
Can the applicant self-administer medications?
Medications: Be sure to include over the counter medications.
Medication
Dosage
Time/Frequency
PART VII: Medical Contacts
Other physicians, CRNP (include names and phone number):
Preferred Hospital:
Preferred Medical Transport Company:
PART VIII: Caregiving
What other community agencies (home health or social service) do you currently use or have used?
Agency
Reason
Do you have a care manager?
Are there other caregivers besides the responsible party listed on the front page? __________________
If yes, please list:
Relationship:
Limitations, problems, or restraints on primary caregiver?
What is the extent of the perceived burden on the caregiver(s)?
Does the caregiver feel the need for support? If yes, explain:
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Adult Day Center Intake Screening
PART IX: ADLs, IADLs, and Physical Aids
Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)
Levels of Assistance:
0 = Independent – Completes task independently
1 = Minimum Assistance – Occasional assistance or supervision may be necessary
2 = Moderate Assistance – Assistance or supervision is always needed
3 = Maximum Assistance – Totally Dependent on other
Activity
Ind
Min
Mod
Max
Primary
Comments
0
Assist
Assist
Assist
Source of
1
2
3
Help
Mobility
Transferring
Bathing
Grooming
Personal Hygiene
Eating
Toilet Use
Meal Preparation
Laundry
Shopping
Light Housework
Home Maintenance
Telephone
Financial Management
Transportation
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Adult Day Center Intake Screening
Medical Devices Used:
Walker
Cane
Wheelchair
O
2
Prosthetics
Glasses
Hearing Aid
Dentures
Hospital Bed
Catheter
Feeding Tube
Ostomy
Other:
Notes about devices used:
PART X: Nutrition
Special Diet? If yes, explain:
Appetite: Good
Fair
Poor
Allergies to any foods? If yes, list:
How many meals are consumed in a day? 1
2
3
Snacks
Chewing or swallowing problems?
Troublesome foods? If yes, explain:
Are there any special instructions for meal times?
PART XI: Cognitive/Behavioral Status
Is the applicant oriented to Person? Yes
No
Place?
Yes
No
Time?
Yes No
Is the applicant’s recent (short term) memory: Good Fair Poor
Is the applicant’s distant (long term) memory:
Good Fair Poor
What is your favorite family vacation memory?
Is the applicant able to understand verbal directions? Yes No
Is the applicant able to communicate needs (thirst, bathroom, hunger, etc.)?
Yes
No
If yes, how?
Is the applicant able to understand written directions? Yes No
Is the applicant aware of danger, risks, and consequences? Yes No
Any recent stressful events? If yes, describe:
What is the applicant’s response to illness?
Circle any behaviors the applicant has experienced:
depressed
anxious
paranoid
aggressive
agitated
withdrawn
suicidal thoughts
other:
Is the applicant receiving any mental health treatment? If yes, describe:
Is the applicant experiencing any current emotional problems or related behaviors such as wandering or
sleeplessness? If yes, describe:
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