Healthcare Assisted Living Questionnaire

HEALTHCARE ASSISTED LIVING QUESTIONNAIRE

Resident Information

Date of Birth:     Gender: Male Female Other

Phone:     Email:

Emergency Contact

Relationship:     Phone:

Authorized Representative / Legal Guardian (if applicable)

Relationship to Resident:     Phone:

Insurance and Primary Care

Policy Number:     Group Number:

Clinic Phone:     Last Visit Date:

Medical History

Please indicate medically diagnosed chronic conditions (check all that apply):

Diabetes     Hypertension     Heart disease     COPD / Respiratory disease

Dementia / Alzheimer’s     Kidney disease     Cancer     Other:

Functional Status and Assistance Needs

Activities of Daily Living where assistance is required (check all that apply):

Bathing     Dressing     Toileting     Transferring (bed/chair)     Eating     Medication management

Mobility aids used (check all that apply):

Cane     Walker     Wheelchair     Scooter     Bedbound

Fall history: Date of last fall:     Number of falls in past 12 months:

Continence status (check all that apply):

Continent     Needs assistance with toileting     Urinary incontinence     Bowel incontinence

Cognitive / Behavioral status (select one):

Independent / Oriented     Mild impairment / requires reminders     Moderate impairment / requires supervision     Severe impairment / extensive assistance

Behavioral concerns (check all that apply):

Wandering     Agitation / aggressive behavior     Self-harm risk     Other:

Dietary and Nutrition

Recent unintentional weight change in past 6 months:

Medical Devices and Treatments

Oxygen therapy     Feeding tube     Tracheostomy     Dialysis

Other treatments or equipment required:

Permissions and Authorizations

I authorize the assisted living provider to obtain and share relevant medical information with healthcare practitioners as necessary for the provision of care, treatment, billing, and emergency care. I understand that this authorization permits release of protected health information to facilitate care coordination and is limited to information reasonably necessary for these purposes.

I authorize release of medical information as described above.

Authorization expiration date:

In the event of an emergency, I authorize facility staff to arrange for necessary medical treatment and transportation to an emergency facility when immediate treatment is required and the authorized representative is not available. I understand facility staff will make reasonable efforts to contact my emergency contact or authorized representative.

I authorize emergency treatment as described above.

I consent to assistance with medication administration by authorized facility staff where applicable. I understand that medication administration will follow facility policies and the resident's physician orders.

I consent to facility-administered medications.

HIPAA / Privacy Acknowledgment

I acknowledge that I have received and reviewed the facility's privacy practices and understand my rights regarding the privacy and confidentiality of my protected health information. I understand how my information may be used and shared for treatment, payment, and healthcare operations.

I acknowledge receipt of the facility privacy practices and understand my rights.

Additional Clinical Information

Certification and Acknowledgment

I certify that the information provided on this questionnaire is true, accurate, and complete to the best of my knowledge. I understand that omission of material information may affect the resident's eligibility for services. I authorize the facility to verify the information provided and to obtain additional information from healthcare providers as necessary to plan and deliver appropriate care.

I understand that I may revoke authorizations provided here at any time in writing, except to the extent that action has already been taken in reliance on the authorization. This questionnaire does not constitute an enrollment agreement or guarantee of placement; specific terms and conditions of service will be addressed in separate agreements as required by the facility.

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