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AMBULATORY STATUS (this person is ambulatory nonambulatory)
Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device
other than a cane. An ambulatory person must be able to do the following:
YES NO
Able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.
Mentally and physically able to follow signals and instructions for evacuation.
Able to use evacuation routes including stairs if necessary.
Able to evacuate reasonably quickly (e.g., walk directly the route without hesitation).
FUNCTIONAL CAPABILITIES (Check all items below)
YES NO
Active, requires no personal help of any kind - able to go up and down stairs easily
Active, but has difficulty climbing or descending stairs
Uses brace or crutch
Frail or slow
Uses walker. If Yes, can get in and out unassisted? Yes No
Uses wheelchair. If Yes, can get in and out unassisted? Yes No
Requires grab bars in bathroom
Other: (Describe)
SERVICES NEEDED (Check items and explain)
YES NO
Help in transferring in and out of bed/turning in bed or chair (specify) _________________________________________________________
Help with bathing__________________________________________________________________________________________________
Help with dressing, hair care, and personal hygiene (specify) _______________________________________________________________
Does prospective resident desire and is he/she capable of doing own personal laundry and other household tasks? (specify) _____________
Help with moving about the facility ____________________________________________________________________________________
Help with eating (need for adaptive devices or assistance from another person)_________________________________________________
Special diet/observation of food intake _________________________________________________________________________________
Toileting, including assistance equipment, or assistance of another person (specify) _____________________________________________
Continence, bowel or bladder control. Are assistive devices such as a catheter required? _________________________________________
Help with medication _______________________________________________________________________________________________
Needs special observation/night supervision (due to confusion, forgetfulness, wandering) _________________________________________
Help in managing own cash resources _________________________________________________________________________________
Help in participating in activity programs________________________________________________________________________________
Special medical attention ___________________________________________________________________________________________
Assistance in incidental health and medical care _________________________________________________________________________
Other “Services Needed” not identified above ___________________________________________________________________________
Is there any additional information which would assist the facility in determining applicant’s suitability for admission?
Yes No
If Yes, please attach comments on separate sheet.
TO THE BEST OF MY KNOWLEDGE, I/THE ABOVE PERSON DO/DOES NOT NEED SKILLED NURSING CARE.
SIGNATURE OF APPLICANT OR RESPONSIBLE PERSON DATE COMPLETED
SIGNATURE OF LICENSEE OR DESIGNATED REPRESENTATIVE DATE COMPLETED
