2528-XXXX; expiring XX-XX-XXXX
PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN:
The public reporting burden for this information collection is estimated to be 80 minutes. This burden estimate includes time for reviewing instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the information. Send comments regarding the accuracy of this burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Federal Investigative Services, Attn: OMB Number (3206-0246), 1900 E Street NW, Washington, DC 20415-7900.
The information requested under this collection is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C.552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.
Please use this paper version of the health and wellness assessment for times when you cannot enter information directly into the demonstration’s online platform, hosted by Population Health Logistics (PHL). After completing the paper assessment, please follow the IWISH PHL User Guide for instructions on how to enter the data into PHL.
Participant Information |
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Male Female Transgender Does Not Declare Other |
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English Spanish Albanian Arabic Cambodian Chinese-Cantonese Chinese –Mandarin Farsi French Creole German Greek Hindi Italian Korean Persian Portuguese Russian Tagalog Twi Ukrainian Vietnamese Other _____________ |
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Married Never Married Divorced Single Widowed Separated Other ______________ |
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American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or Other Pacific Islander White Other _______________ |
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________ - ______- _________ |
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Yes No |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Participant Contact Information |
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Add Address |
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Home Mailing Other |
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Yes No |
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Add Phone |
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Home Mobile Work Other |
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_____-_____-______ |
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Yes No |
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Add Email |
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Personal Family Member Email Address Other |
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Yes No |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions
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Insurance *Ability to add multiple insurance policies. Space for two is included below. |
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Medicare Part A (Hospital Coverage) Medicare Part B Medicare Part C (Medicare Advantage) Medicare Part D (Prescription Coverage) Medicare Supplemental (Medigap) Medicaid PACE Tricare Veteran’s Affairs Commercial Insurance Uninsured Other |
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Medicare Part A (Hospital Coverage) Medicare Part B Medicare Part C (Medicare Advantage) Medicare Part D (Prescription Coverage) Medicare Supplemental (Medigap) Medicaid PACE Tricare Veteran’s Affairs Commercial Insurance Uninsured Other |
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Medicare Part A (Hospital Coverage) Medicare Part B Medicare Part C (Medicare Advantage) Medicare Part D (Prescription Coverage) Medicare Supplemental (Medigap) Medicaid PACE Tricare Veteran’s Affairs Commercial Insurance Uninsured Other |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Contacts *Ability to add multiple contacts. Space for three contacts is included below. |
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Contact Details – Contact #1 |
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Spouse Son Daughter Daughter-in-law Son-in-law Sister Brother Spouse Equivalent Friend Neighbor Granddaughter Grandson Nephew Niece Other |
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Health Care Financial Health Care and Financial Not Applicable |
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Yes No Pending |
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Phone Email Phone or Email Fax Mail Other |
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Daily 2-3 times weekly Weekly 2-3 times/month Several times/year As-needed Other |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Home Other |
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Yes No |
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Home Mobile Work Other |
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_____-_____-_______ Ext: (_______) |
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Yes No |
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Personal Family Member Office Other |
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Yes No |
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Contact Details – Contact #2 (if applicable) |
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Spouse Son Daughter Daughter-in-law Son-in-law Sister Brother Spouse Equivalent Friend Neighbor Granddaughter Grandson Nephew Niece Other |
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Health Care Financial Health Care and Financial Not Applicable |
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Yes No Pending |
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Phone Email Phone or Email Fax Mail Other |
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Daily 2-3 times weekly Weekly 2-3 times/month Several times/year As-needed Other |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Home Other |
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Yes No |
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Home Mobile Work Other |
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_____-_____-_______ Ext: (_______) |
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Yes No |
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Personal Family Member Office Other |
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Yes No |
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Contact Details – Contact #3 (if applicable) |
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Spouse Son Daughter Daughter-in-law Son-in-law Sister Brother Spouse Equivalent Friend Neighbor Granddaughter Grandson Nephew Niece Other |
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Health Care Financial Health Care and Financial Not Applicable |
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Yes No Pending |
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Phone Email Phone or Email Fax Mail Other |
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Daily 2-3 times weekly Weekly 2-3 times/month Several times/year As-needed Other |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Home Other |
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Yes No |
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Home Mobile Work Other |
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_____-_____-_______ Ext: (_______) |
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Yes No |
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Personal Family Member Office Other |
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Yes No |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Participant Resources |
Specify which resources/services the participant currently receives in this section. Please use one row for each service and specify the Agency Type, the Category of Service Provided, the Type of Service, Date Service Began, and Current Service Status. A table listing the different types of services for each category is available following this section. |
Service Number |
Agency Type |
Service Category |
Service Type |
Date Service Began |
Service Status |
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Indicate one:
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Indicate one:
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See choices following this table |
If known |
Indicate one:
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Participant Resources: Category of Services and Associated Type of Service Please use this table as a reference when completing the Participant Resource portion that precedes this section. This table defines the types of services within each service category. |
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Category of Service |
Type of Service |
Case Management Services |
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Food |
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Housing |
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Home Modification |
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Utility Assistance |
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Transportation |
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Medical
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Financial |
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Legal |
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Employment |
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Education |
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Other |
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Immunizations |
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Immunization |
Status (select one) |
Approximate Immunization Date |
Notes |
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Yes No Unknown No - Medical Reason |
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Yes No Unknown No - Medical Reason |
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Yes No Unknown No - Medical Reason |
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Yes No Unknown No - Medical Reason |
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Yes No Unknown No - Medical Reason |
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Yes No Unknown No - Medical Reason |
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Yes No Unknown No - Medical Reason |
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Yes No Unknown No – Medical Reason |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
General Information |
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Advance Directive, DNR, and POAs |
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Yes No Unknown |
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Yes No Not Now N/A |
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Family Member Home MD Office Preferred Hospital Other N/A |
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Yes No Unknown |
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Family Member MD Office Healthcare Power of Attorney Preferred Hospital Other N/A |
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Yes No Unknown |
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Yes No Unknown |
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Household, Assistive Devices, and Transportation |
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Yes No |
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Own Car Bus Support Person Transportation Agency Other |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Clinicians Please include the participant’s Primary Care Provider and key specialists the participant regularly visits. |
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Primary Care Provider |
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_____-_____-________ |
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_____-_____-________ |
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Specialist #1 |
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Oncologist Neurologist Psychologist Psychiatrist Cardiologist Ophthalmologist/Optometrist OBGYN Other _______________________ |
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Specialist #2 |
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(select one) |
Oncologist Neurologist Psychologist Psychiatrist Cardiologist Ophthalmologist/Optometrist OBGYN Other _______________________ |
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Specialist #3 |
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Oncologist Neurologist Psychologist Psychiatrist Cardiologist Ophthalmologist/Optometrist OBGYN Other _______________________ |
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_____-_____-________ |
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_____-_____-________ |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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General Health Assessment |
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Annual Exams, Hospitals, and Surgery |
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Excellent Very Good Good Fair Poor Unknown |
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Yes No Unknown |
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Yes No Unknown |
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Specific Health Questions |
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Yes No |
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Cane Motorized Scooter Walker Wheelchair |
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Eyeglasses Hearing aids Dentures None Other |
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Yes No |
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Calluses Corns Cuts Bruises Fungus Overgrown Toenails Ingrown Toenails Dry Skin N/A Other |
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Zero One Two Three Four Five Six Seven |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Diagnosis |
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Diagnosis (select all that apply) |
Notes |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Medication |
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Medication Name |
Strength (i.e. dosage) |
Units |
Dosage Frequency |
Dosage Number |
Dosage Method |
Special Instructions |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Medication Review |
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Medication #1 (enter name of medication): __________________________ |
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New taken < 1 week Ongoing Review requested Discontinued Prescription not filled Refill overdue Other |
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Yes No N/A |
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Yes No N/A |
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Self (i.e., the participant) Caregiver RN Unknown Other |
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Bag Bathroom cabinet Refrigerator Bathroom counter Box Kitchen cabinet Kitchen counter Mixed containers Multiple locations Night stand Other |
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Yes No N/A |
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Yes No N/A |
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Yes No N/A |
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Yes No N/A |
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Medication #2 (enter name of medication): __________________________ |
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New taken < 1 week Ongoing Review requested Discontinued Prescription not filled Refill overdue Other |
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Yes No N/A |
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Yes No N/A |
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Self (i.e., the participant) Caregiver RN Unknown Other |
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Bag Bathroom cabinet Refrigerator Bathroom counter Box Kitchen cabinet Kitchen counter Mixed containers Multiple locations Night stand Other |
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Yes No N/A |
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Yes No N/A |
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Yes No N/A |
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Yes No N/A |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Supplemental Mediation Review sheets are available at the end of this Assessment for printing when necessary.
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Morisky 8-Item Medication Adherence Questionnaire |
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Question |
Patient Answer |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Never/rarely Once in a while Sometimes Usually All the time |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Allergies |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
Vitals |
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Absent +1 +2 +3 +4 |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Physical Self-Maintenance Scale (PSMS): Activities of Daily Living (ADLs) |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Instrumental Activities of Daily Living (IADLs) |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Independent Needs Assistance |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Nutrition Screen (DETERMINE) |
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These questions identify older persons at risk for low nutrient intake and subsequent health problems. Communicate to participant: “What you eat does affect your health. These questions help us determine any if you are at nutritional risk.” Summing the scores associated with each Yes answer indicates:
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Yes (2) No (0) |
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Yes (3) No (0) |
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Yes (1) No (0) |
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Yes (1) No (0) |
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Yes (4) No (0) |
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Yes (2) No (0) |
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Yes (1) No (0) |
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Yes (2) No (0) |
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Yes (2) No (0) |
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Yes (2) No (0) |
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Yes (1) No (0) |
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Total Score: |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Falls Risk Assessment (STEADI) These questions identify persons at risk for falling. Sum the scores associated with each “Yes” answer. Scores of 4 points or more indicate the participant may be at risk for falling. |
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Question |
Why it matters |
Answer |
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People who have fallen once are likely to fall again. |
Yes (2) No (0) |
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People who have been advised to use a cane or walker may already be more likely to fall. |
Yes (2) No (0) |
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Unsteadiness or needing support while walking are signs of poor balance. |
Yes (1) No (0) |
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This is also a sign of poor balance. |
Yes (1) No (0) |
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People who are worried about falling are more likely to fall. |
Yes (1) No (0) |
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This is a sign of weak leg muscles, a major reason for falling. |
Yes (1) No (0) |
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This is also a sign of weak leg muscles. |
Yes (1) No (0) |
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Rushing to the bathroom, especially at night, increases your chance of falling. |
Yes (1) No (0) |
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Numbness in your feet can cause stumbles and lead to falls. |
Yes (1) No (0) |
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Side effects from medicines can sometimes increase you a chance of falling. |
Yes (1) No (0) |
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These medicines can sometimes increase your chance of falling. |
Yes (1) No (0) |
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Total Score: |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Mini Cog |
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Begin the cognitive assessment with word recall.
Have the participant repeat the following three words right after you say them: Telephone, umbrella, flowers. This is to make sure they heard and understood the words correctly.
Next, provide a blank piece of paper to the participant and ask them to do the following steps:
Keep the clock drawing.
Ask the participant, “Please tell me the three words I asked you to remember earlier.” Note how many words the participant was able to recall.
Next, is the category fluency, please make sure you have a timing device available. Say, “When I tell you to start, please name as many kinds of animals as you can think of in one minute. Ok?” When the person is ready. Say, “begin” and start the timer. At the end of 60 seconds stop the timer and say, “Ok, that’s good. Thank you.” Keep track of how many animals they named here (which animal is not important).
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5-7 points = passing score 4 points = borderline 0-3 points = failing score |
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3 points = passing score 2 points = borderline 1-0 points = failing score |
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>15 animals named within the one minute = passing score 15 animals = borderline <15 animals = failing score |
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Pass Fail |
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Yes No |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Use this page for the Mini Cog: |
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Use this page for the Mini Cog: |
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Loneliness Scale |
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The scores of each individual question can be added together to give range of scores from 3 to 9. Researchers have grouped people who score 3-5 as “not lonely” and people with a score of 6-9 as “lonely.” |
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Hardly ever (1) Some of the time (2) Often (3) Not performed |
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Hardly ever (1) Some of the time (2) Often (3) Not performed |
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Hardly ever (1) Some of the time (2) Often (3) Not performed |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
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Behavioral Health |
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Zero One Two Three or more times |
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If answer above is “Two” or “Three or more,” complete the S-MAST-G below. |
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Never Former Current tobacco user Currently exposed to second hand smoke No for medical reasons |
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Yes No Not now N/A |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions |
S-MAST-G
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Two or more “Yes” answers below indicate the need for a brief intervention and possibly a referral for assessment and treatment. |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes No |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions Not applicable |
General Anxiety Disorder Scale (GAD-2) |
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0 – Not at all 1 – Several days 2 – more than half the days 3 – Nearly every day |
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0 – Not at all 1 – Several days 2 – more than half the days 3 – Nearly every day |
Total Score: |
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If the total score from two GAD-2 questions above is 3 or higher, complete GAD-7 below. |
General Anxiety Disorder Scale (GAD-7) |
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Scoring: Sum points from all GAD-7 answers: 5-9 Mild Anxiety, 10-14 Moderate Anxiety, 15 + Severe Anxiety |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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Not difficult at all Somewhat difficult Very difficult Extremely difficult |
Total Score: |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions Not applicable |
Patient Health Question-2 (PHQ-2): Depression Screener |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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Total Score: |
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If the total PHQ-2 score is 3 or greater complete the PHQ-9 |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions
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Patient Health Question-9 (PHQ-9) For participants who scored 3 or greater total points on the PHQ-2 complete this section. . |
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Ask the participant: “Over the past two weeks, how often have you been bothered by any of the following problems?” |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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0-Not at all 1-Several Days 2-Over Half of the Days 3-Nearly Every Day |
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Total Score: |
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Take the total score from PHQ-2 and add to the sum of the additional questions. 0-4 = minimal depression, 5-9 = mild, 10-14 = moderate, 15-19 = moderately severe, 20-27 = severe. |
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Yes – section completed in full No – not yet completed No – participant refused to answer one or more questions Not applicable |
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Assessment Status |
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Participant declined to complete one or more sections Participant did not respond to at least three attempts to contact Participant already has completed an assessment with another program Other reason
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Supplemental Medication Review |
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Medication (enter name of medication): __________________________ |
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New taken < 1 week Ongoing Review requested Discontinued Prescription not filled Refill overdue Other |
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Yes No N/A |
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Yes No N/A |
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Self (i.e., the participant) Caregiver RN Unknown Other |
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Bag Bathroom cabinet Refrigerator Bathroom counter Box Kitchen cabinet Kitchen counter Mixed containers Multiple locations Night stand Other |
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Yes No N/A |
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Yes No N/A |
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Yes No N/A |
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Yes No N/A |
FOR INTERNAL USE ONLY – DO NOT DISTRIBUTE
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Vahouny, Evan |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |