Elizabeth Residence New Berlin

FAMILY ASSESSMENT

Elizabeth Residence New Berlin

Please take the time to circle the areas that apply to your relative or friend. Some of these areas concern physical status and some relate to normal behaviors for individuals with Alzheimer’s/Dementia. The information you provide will help us prepare for a well-planned admission.

Resident Name______Nickname______

Sight/Vision

Normal Right Eye Left Eye

Partial or impaired (corrected with lenses)Right EyeLeft Eye

Partial or impaired (not corrected with lenses)Right EyeLeft Eye

Legally blindRight EyeLeft Eye

Hearing

Normal-hears adequatelyRight EarLeft Ear

Uses hearing aidRight EarLeft Ear

Hearing impaired (can hear if spoken loudly)Right EarLeft Ear

Diet

Special Likes: ______

Dislikes:______

Dentures: Upper Lower

Ambulation

Normal

Ambulates with difficulty (no aids)

Ambulates with aids (walker, cane)

Wheelchair (propels self without difficulty

Wheelchair (difficult in use)

Wheelchair (unable to use independently)

Elimination

Normal (Toilets self without assistance)

Occasional incontinence (Needs reminders but independent)

Incontinent of bowels or bladder (circle 1 or both)

Uses incontinence supplies

Who should be called for incontinence supplies:

□Family: (name&#)______

□Our Pharmacy – Prescriptions Plus

□Community Care ______

Bathing Prefers: Baths / Showers / Sponge baths

Mornings About what time does this resident wake up in the morning? ______

Interests

Crafts (describe)______

Watch TV (which shows?)______

Games (which kind?)______

Read books/Magazines (Type)______

Household tasks (Examples)______

Music(what kind?)______

Attend Church (Religion)______

Write letters (assistance needed?)______

Movies (what type)______

Circle all that apply

Cooking SewingBingoPuzzlesWord SearchGardening

BowlingSinging Socials/Parties Wood Working Outings/Field trips

Other interests: ______

Can this resident have alcohol (in moderation) with special events and activities? Yes No

Does this resident want to continue to become a registered voter? Yes No

Does this resident need large print items? Yes No

Did this resident serve in the military? What branch? ______Yes No

Any other significant people that are involved in this resident’s life and their relationship:

Our facility is prepared to cope with behaviors that are normal for people with Alzheimer’s disease or dementia. Please circle any behaviors which your relative/friend exhibits.

Behavior

People are stealing things

People are coming into home and hiding things

Talking and listening to people coming into home

Feels that spouse or caregiver is an imposter

Feels that spouse is unfaithful

Does this resident:

Lose or misplace thingsRepeats questions or demands

Pacing, restlessness, wanderingWanders away from home

Constantly follows caregiverExpresses fear of being alone

Inappropriate sexual behaviorHas persistent complaints

Hides or hoards objectsTears up easily

Repeatedly removes clothingwrings hands or other anxious behavior

Repetitive behaviorBehavior changes related to time of day (explain)

Reaction to Delusion

Verbal threats and accusationsSwears

Anger outburstsViolet behaviors (slapping, biting)

Hallucinations

Sees things or people that are not thereHears words or phrases? Yes or No

Any other information you feel it is important we know:______

______

______

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Person completing this form: ______

Relationship______

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