APPENDIX C
IN-PERSON ASSESSMENT INSTRUMENT
(FOR USE AS BOTH INITIAL AND FINAL ASSESSMENT)
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Referral Number:
Participant Name:
Address:
Phone Number:
Independent Living
and
Mobility Program
In-Person Interview
Assessor
–
Print your name with credentials and the date that the interview was completed.
Name and credentials:
______________________________________________
Date of interview: __________________________________________________
Was more than one person in this household interviewed?
.......................................................................
No
Yes
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1.
Instructions
Please read this paragraph to the participant before beginning the interview.
My name is ______________, and I will be interviewing you and taking
your height, weight and blood pressure readings as part of the Independent
Living and Mobility Program.
The interview takes approximately one hour. I will be asking questions
about your health and daily activities and will perform a brief home safety
evaluation.
I will be asking you questions on a number of different topics. Some of these
questions may or may not be applicable to you; but it is important that we
ask all participants the same questions.
If this is the initial in-person assessment add:
The information from this interview will be sent to the home office where a
report will be created that highlights things you can do to improve your
safety and reduce the chance of falling in your home. This report will then
be sent to you. Along with the summary, a Health Promotion and
Independent Living and Mobility Tool kit will be sent to you that contains
1)
Health and Home Safety Handout,
2)
Wipe-Off Medication Management Planner,
3)
Exercise video,
4)
Exercise Progress Chart,
5)
Falls Journal in which you can record any falls or near falls that may occur and
6)
Pedometer.
Additionally, you will be receiving a quarterly follow-up phone call shortly
after this interview. In the interim, if you have any questions regarding the
Independent Living and Mobility Program, please contact XXXXXXXX at XXX-
XXX-XXXX.
If this is the final in-person assessment add:
This is the final interview that we will be conducting, thank you for
participating in this important national program over the past 2 years.
For all assessments finish the introduction with:
Do you have any questions regarding the interview before we begin?
Please document any questions the participant has.
_______________________________________________________
_______________________________________________________
_______________________________________________________
Enter the time the
interview begins
(i.e. 2:53 PM).
Exact time:
:
am/pm
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2.
General Questions
A.
Do you have any visual deficits? (If “Yes,” explain below) .............................................................................................................
No
Yes
B.
Do you have any hearing deficits? (If “Yes,” explain below)...........................................................................................................
No
Yes
Condition
Date of
Diagnosis
(month/year)
Dr. Name
Treatment
Current Status
C.
Are you having any difficulty understanding me? (If “Yes,” explain below) ....................................................................................
No
Yes
Reason for difficulty:
What can be done to compensate for this problem?
A.
Assessor:
compensate as best you can and then ask:
Now can you understand me? (If “No,” terminate interview).......................................................
No
Yes
3.
Hospital/Emergency Visits and Surgery
A.
Since your recent phone interview have you had any Hospital Admissions, Emergency Room visits or Surgery?........................
No
Yes
If Yes, indicate number of times: _________
Reason for Hospital Admission/
Emergency Room visit/ Surgery
Date
(month/year)
Type of Surgery &/or
Treatment received
Current Status
4.
Primary Care Physician
A.
Do you have a primary care physician? .......................................................................................................................................
No
Yes
Physician’s name: ____________________________Phone number:_____________________
City: ______________________ State __________Street address:
____________________
Specialty: ___________________
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5.
Falls History
A.
Since your recent phone interview have you had one or more episodes of fainting, falling or dropping
to the ground, passing out or have you lost your balance, slipped or tripped over something that
resulted in falling or dropping to the ground?....................................................................................................................
No
Yes
If Yes, How many times did this happen? ______________________________________
Regarding your most recent fall, what time of day did it happen? .......................................................
Day
Eve
Morn/Day
5:01AM-9:00AM
9:01AM-12:00PM
12:01PM-4:00PM
Eve/Noc
5:01PM-7:00PM
7:01PM-10:00AM
10:01AM-5:00AM
Did you get hurt or injure yourself?......................................................................................................
No
Yes
Did you require Medical Attention? ......................................................................................................
No
Yes
Emergency Room Visit
Hospital Admission
Doctor Visit
What were you doing when you fell? ______________________________________
_________________________________________________________
Were you at home when you fell? ........................................................................................................
No
Yes
If Yes, Where?
Bathroom
Kitchen
Entryway
Stairs
Other:
If No, Where?
Store/Business
Parking Lot/Street
Relative/Friend House
Dr. Office
Walkway/Pathway
Other
_____________
What was the cause of your fall?
Tripped
Slipped
Dizziness
Seizure
Loss of Balance
Fainted/Blacked out
Other:
Were any of the following conditions present when you fell? (read all)
Ground conditions
Wet Ground .........................................
No
Yes
Icy/snowy Ground ...............................
No
Yes
Uneven Ground....................................
No
Yes
Stepping up onto/down from a Curb ....
No
Yes
Climbing up/going down stairs ............
No
Yes
Object in walkway/path.......................
No
Yes
Behaviors For each Yes, answer additional question
Additional Question
Wearing shoes that did not fit properly ..
No
Yes
Have you changed this behavior?..................
No
Yes
Wearing clothes that did not fit properly.
No
Yes
Have you changed this behavior?..................
No
Yes
Not using necessary visual aid/glasses...
No
Yes
Have you changed this behavior?..................
No
Yes
Not using necessary equipment ..............
No
Yes
Have you changed this behavior?..................
No
Yes
(cane, walker, shower seat, grab bars)
No
Yes
B.
Have you been anxious or worried or afraid you might fall?...........................................................................................
No
Yes
C.
Do you ever limit your activities, for example, what you do or where you go because you are afraid of
falling?..........................................................................................................................................................................................
No
Yes
If Yes, Which activities and why? ____________________________________________
________________________________________________________________
How often?
All of the time
Some of the time
Rarely
Doesn’t know
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6.
Medications
A.
Please tell me the names and dosages of all the medications you currently take including non-prescription
medications, eye drops and inhalers. (Assessor - Please obtain details for all medications)
Medication Name
Dosage
Frequency
If PRN,
indicate how
often used
Reason for taking
Do you take
this as
prescribed by
your doctor?
If NO, Why Not?
Too Expensive,
Side Effects;
“I don’t need them”,
”They don’t work”,
Ran out of Rx,
Forgets, Other:
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
5
Yes
No
6
Yes
No
7
Yes
No
8
Yes
No
9
Yes
No
10
Yes
No
11
Yes
No
12
Yes
No
13
Yes
No
14
Yes
No
15
Yes
No
16
Yes
No
17
Yes
No
18
Yes
No
19
Yes
No
20
Yes
No
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7.
Medical Conditions and Symptoms
A.
Do you have a history of any of the following conditions? (if any answer is “Yes,” explain below)
Irregular Heart Beat/A-fib/Arrhythmia..............
No
Yes
Sciatica, Back pain or swelling........................
No
Yes
High Blood Pressure ..........................................
No
Yes
Foot Disorders................................................
No
Yes
Low Blood Pressure ...........................................
No
Yes
Ankle, Knee or Hip replacement.....................
No
Yes
Congestive Heart Failure ...................................
No
Yes
Ankle, Knee or Hip pain, swelling or redness.
No
Yes
Heart Attack ......................................................
No
Yes
Amputation of Leg, Foot or Toe ......................
No
Yes
Any other heart problem(s)................................
No
Yes
Cancer, Leukemia, Lymphoma........................
No
Yes
Vitamin B12 Deficiency or Anemia .....................
No
Yes
Diabetes.........................................................
No
Yes
Other blood disorder?........................................
No
Yes
Numbness (where?)..................................
No
Yes
Circulatory Problems .........................................
No
Yes
Weakness (where?) ..................................
No
Yes
Stroke, TIA or “Mini-Stroke” ..............................
No
Yes
Fatigue ...........................................................
No
Yes
Paralysis (where?) .......................................
No
Yes
Tremors (where?) .....................................
No
Yes
Peripheral Neuropathy ......................................
No
Yes
Seizures, convulsions (date of last).........
No
Yes
Multiple Sclerosis...............................................
No
Yes
Neurological Problems ...................................
No
Yes
Parkinson’s Disease ..........................................
No
Yes
Unsteadiness/Imbalance ................................
No
Yes
Alzheimer’s Disease/Dementia..........................
No
Yes
Psychiatric Disorders .....................................
No
Yes
Shortness of breath/Difficulty Breathing............
No
Yes
Depression .....................................................
No
Yes
Asthma, Emphysema, COPD, Chronic Cough.......
No
Yes
Anxiety ..........................................................
No
Yes
Arthritis (Type? Location?) ....................
No
Yes
Alcoholism/Drug Addiction .............................
No
Yes
Osteoporosis .....................................................
No
Yes
Dizziness/Vertigo ...........................................
No
Yes
Bone Fractures (where? why?)................
No
Yes
Insomnia/difficulty sleeping ..........................
No
Yes
B.
If any condition
is answered “Yes,” gather details in the grid below
Condition
Date of
Diagnosis/
1
st
Symptom
Date of most
recent
Symptom
Is Condition
treated by a
doctor?
Is Condition
Controlled/
Stable?
Treatment
1
No
Yes
No
Yes
2
No
Yes
No
Yes
3
No
Yes
No
Yes
4
No
Yes
No
Yes
5
No
Yes
No
Yes
6
No
Yes
No
Yes
7
No
Yes
No
Yes
8
No
Yes
No
Yes
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9
No
Yes
No
Yes
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8.
Physical Measurements
Some falls occur when people stand up from a lying position because their blood pressure drops. Therefore, I
would like to take your blood pressure from two positions – one when you are lying down, then one after you
stand up from a lying position. Please lie down on a couch for the first blood pressure and pulse.
A. Supine BP: _____ / _____
Exact Time: ____: _____ (wait no more than 1 minute before taking standing BP)
& Heart rate:_____
What does your blood pressure usually run? _____ / _____ or
Unknown
Now please stand up and I will take your blood pressure and pulse again.
B. Standing BP: _____ / _____
Exact Time: ____: _____
& Heart rate:_____
C. Height: ____ft._____ in.
Have you had any loss of height? .............................................................................
No
Yes
How much?
Reason:
D. Weight: _________ lbs.
9.
Activities of Daily Living & Physical Performance Measurements
The next questions concern your
current ability to perform daily activities. I will first ask if you have any
difficulty doing the activity, then if you receive any assistance or use any equipment and then I will ask you to
demonstrate the motions that are required to complete the activities. I will also be asking to do a safety
evaluation in your kitchen, bedroom, the bathroom that you use most often and the rooms in which you spend
most of your time.
Assessor: As you view each room, look to see that flooring is securely attached (including
area rugs), walkways are well lit and clear of obstructions, thresholds are only ½ inch high, furniture is sturdy
and note any nightlights that are used regularly.
B.
Transferring:
1.
Do have difficulty when transferring in or out of a bed or chair without assistance from another person? .............................
No
Yes
1.
_________________________________________________________________
If Yes,
Describe
why completion of this activity is difficult for you:
_________________________________________
2.
____________________________________________________________
3.
____________________________________________________________
4.
____________________________________________________________
2.
Does anyone help you transfer in and out of a bed or chair?...................................................................................................
No
Yes
3.
Do you use equipment when transferring from a bed or chair? ...............................................................................................
No
Yes
5.
_________________________________________________________________
If Yes identify
type:
hoyer lift
chair lift
walker
cane
other___________
4.
Please stand up then sit back down for me.
Assessor: Did the participant have any difficulty completing this task?
........................................................
No
Yes
6.
If Yes, choose one and explain:
Difficulty noted
Not completed,
safety issue
7.
____________________________________________________________
8.
____________________________________________________________
9.
____________________________________________________________
10.
___________________________________________________________
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5.
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
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C.
Mobility Outside:
1.
Do have difficulty when walking outside your home (within walking distance) including negotiating uneven surfaces (curbs,
ramps, sidewalks, uneven ground etc…) without assistance from another person? ..............................................................
No
Yes
11.
___________________________________________________________
If Yes,
Describe
why completion of this activity is difficult for you:
_____________________________________
12.
___________________________________________________________
13.
___________________________________________________________
14.
___________________________________________________________
2.
Does anyone help you when you walk outside your home?.....................................................................................................
No
Yes
3.
Do you require equipment when walking outside your home? ................................................................................................
No
Yes
If yes, identify type:
scooter
wheelchair
walker
cane
other_________
4.
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
D.
Chair stands
1.Baseline Chair Stand
These next exercises measure the strength in your legs. Please sit in a chair that is at a comfortable height.
Do you think it would be safe for you to try to stand up from a chair without using your arms? .........................................
No
Yes
If Yes:
Demonstrate chair stand for participant as you explain and record results below
First fold your arms across your chest and sit so that your feet are on the floor, then try to stand up,
keeping your arms folded across your chest.
Gets up easily on first try....................................................
(continue with #2 below)
Gets up on first try but has difficulty...................................
(continue with #2 below)
Requires more than one attempt .........................................
(continue with #2 below)
Can rise but not without using arms.....................................
(skip to next page)
Cannot rise without assistance from another person ...........
(skip to next page)
Refused to participate ..........................................................
(indicate reason and skip to next page)
Fear of falling
Physically unable
Other:
If No:
Record reason and skip to next page
Cannot rise without assistance from another person ...........
(skip to next page)
Refused to participate ..........................................................
(indicate reason and skip to next page)
Fear of falling
Physically unable
Other:
2.
Timed Chair Stands (do not complete if participant indicates it is unsafe to stand without using arms)
C.
Assessor: use a STOP
WATCH or WATCH WITH A SECOND HAND for this section.
OK, now I am going to ask you to stand up a few more times. Please keep your arms folded across your chest
and stand up straight as many times as you can until I tell you to stop. After standing up each time, sit down
and then stand up again. Keep your arms folded across your chest. I will be timing you for 30 seconds. OK,
are you ready? Stand.
Assessor:
Start timing
and
Count out loud how many times
the
participant rises from the chair during the 30 seconds. Record results below. Stop
timing if there is a safety concern.
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Timed for 30 seconds – Indicate the number of times participant stood from chair during 30 seconds:
_______chair stands
Time stopped due to safety concern at:
seconds. Number of chair stands during that time:
chair stands
Time stopped due to participant’s inability to complete any chair stands with arms folded on chest.
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E.
Mobility Inside & timed get up and go:
1.
Do you have difficulty when walking from one room to another inside your home without assistance from another
person?.................................................................................................................................................................................
No
Yes
15.
___________________________________________________________
If Yes,
Describe
why completion of this activity is difficult for you:
_____________________________________
16.
___________________________________________________________
17.
___________________________________________________________
2.
Does anyone help you walk from one room to another inside your home? .............................................................................
No
Yes
3.
Do you require equipment when performing this activity? ......................................................................................................
No
Yes
If yes, identify type:
stair lift
wheelchair
walker
cane
other_________
4.
Do you think it would be safe for you to stand up from a chair walk 8 feet and back then sit back down? ..............................
No
Yes
D.
If Yes
: Use
Measuring Tape to measure out 8 feet. Stand 8 feet from participant and say:
OK, I am going to time how long it takes you to stand up, walk to here
(8 feet from where participant is
seated),
turn around, walk back and sit down on that seat again. Are you ready?
OK, Go.
(START TIMING and Describe below)
Time taken for participant to rise from chair, walk 8 feet, turn, walk back and sit down again: _______seconds
Posture
:
(e.g. : erect, kyphotic)
___________________________________________
Balance:
(e.g. : steady, imbalanced)
________________________________________
Pace:
(e.g. : fast, medium, slow)
___________________________________________
Stride length:
(e.g. : short, medium, long)
_____________________________________
Step height
:
(e.g. : shuffle, exaggerated, natural)
________________________________
Gait:
(e.g. : smooth, choppy , stiff)
_________________________________________
Arm movement
:
(e.g. : pendulum swing, stiff, bent elbows)
__________________________
Ability to turn
:
(e.g. natural, small steps, unbalanced)
____________________________
Physical Abnormalities/Deformities/Equipment: __________________________________
If No, Why would it not be safe?
Assessor: Did the participant have any difficulty completing this task?...........................................................
No
Yes
18.
If Yes, choose one and explain:
Difficulty noted
Not completed,
safety issue
19.
___________________________________________________________
20.
___________________________________________________________
21.
___________________________________________________________
5.
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
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F.
Four-test balance scale
E.
DO NOT DO this test if participant cannot stand without the assistance of a
person/assistive device or if s/he feels it is unsafe. Use a STOP WATCH or a WATCH WITH A
SECOND HAND for this section. No practices are allowed for these exercises and they should be
carried out in bare feet or stocking feet. You may help the person in to each position, but the person
must hold the position unaided. Each position must be held for 10 seconds before progressing to
the next position.
F.
Stop timing if:
(1) the person moves
their feet from the proper position,
G.
(2) you provide contact
to prevent a fall or
H.
(3) the person touches
the wall or other support with their hand.
I.
Many falls are caused by imbalance, so next I will check your balance. For this exercise, please take off
your shoes. I will ask you to stand in 4 different positions for about 10 seconds each.
1.
Feet Together Stand
First I would like you to try to stand with your feet together, side-by-side, for about 10 seconds
(show picture)
. You may use your arms, bend your knees or move your body to maintain your
balance, but try not to move your feet. Try to hold this position until I tell you to stop.
OK, Start.
(Time for 10 seconds)
Ok, Stop.
(Record result below)
Held position successfully for 10 seconds
Held position successfully, but not for 10 seconds
Unable to hold position/did not do (indicate reason and skip to next page)
Fear of falling
Physically unable
Other: _________________
2.
Semi-tandem stand
Next, I want you to try to stand with the side of the heel of one foot touching the big toe of the other
foot for about 10 seconds
(show picture)
. You may put either foot in front, whichever is more
comfortable for you. You may use your arms, bend your knees or move your body to maintain your
balance, but try not to move your feet. Try to hold this position until I tell you to stop.
OK, Start.
(Time for 10 seconds)
Ok, Stop.
(Record result below)
Held position successfully for 10 seconds
Held position successfully, but not for 10 seconds
Unable to hold position/did not do (indicate reason and skip to next page)
Fear of falling
Physically unable
Other: _________________
3.
Tandem stand
Now, I want you to try to stand with the heel of one foot in front of and touching the toes of the other
foot for about 10 seconds
(show picture)
. You may put either foot in front, whichever is more
comfortable for you. You may use your arms, bend your knees or move your body to maintain your
balance, but try not to move your feet. Try to hold this position until I tell you to stop.
OK, Start.
(Time for 10 seconds)
Ok, Stop.
(Record result below)
Held position successfully for 10 seconds
Held position successfully, but not for 10 seconds
Unable to hold position/did not do (indicate reason and skip to next page)
Fear of falling
Physically unable
Other: _________________
4.
One leg stand
Now, I want you to try to stand on one foot (only if you feel it is safe!), raising the other foot off of the
ground for about 10 seconds
(show picture)
. You may use whichever foot is more comfortable for
you. You may use your arms, bend your knees or move your body to maintain your balance, but try not
to put the other foot down. Try to hold this position until I tell you to stop.
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OK, Start.
(Time for 10 seconds)
Ok, Stop.
(Record result below)
Held position successfully for 10 seconds
Held position successfully, but not for 10 seconds
Unable to hold position/did not do (indicate reason and skip to next page)
Fear of falling
Physically unable
Other: _________________
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G.
Eating
(Note: Eating does not include meal preparation, cooking, cutting food, pouring liquids or buttering bread):
1.
Do you have difficulty eating without assistance from another person?..................................................................................
No
Yes
22.
___________________________________________________________
If Yes,
Describe
why completion of this activity is difficult for you:
_____________________________________
23.
___________________________________________________________
24.
___________________________________________________________
25.
___________________________________________________________
2.
Does anyone help you eat?......................................................................................................................................................
No
Yes
3.
Do you require equipment when eating? .................................................................................................................................
No
Yes
26.
_________________________________________________________________
If Yes identify
type:
Feeding tube
TPN
other:__________
4.
Please demonstrate how you grasp a cup and then a fork or spoon.
(Use pen if fork/spoon not available)
Assessor: Did the participant have any difficulty completing this task?
........................................................
No
Yes
27.
____________________________________________________________
If Yes, choose
one and explain:
Difficulty noted
Not completed, safety issue ________________________
28.
____________________________________________________________
29.
____________________________________________________________
5.
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
H.
Kitchen safety evaluation
Let’s go into the kitchen and I will evaluate the lighting, counter height and flooring.
1.
Is lighting adequate (light bulbs greater than 60 watts) in this room?
..............................................................
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
2.
Are counters and shelves at an appropriate height such that items can be easily reached?
.......................
No
Yes
If No: Explain: ____________________________________________________________
Is a sturdy, non-skid step stool used to reach items outside participant’s reach?
.....
No
Yes
I.
Stairway Safety Evaluation
Next I would like to see any stairs that you use.
1.
Are the stairs used to enter/exit well lit with sturdy railings on both sides?
..............................
None
No
Yes
If No: Explain:
________________________________________________
2.
Are the stairs inside the home well lit with sturdy railings on both sides?
.................................
None
No
Yes
If No: Explain:
________________________________________________
J.
Bedroom safety evaluation
Next I will ask you about dressing, let’s go into the bedroom and I will evaluate the lighting, mattress
safety, flooring and pathway to the bathroom.
1.
Is the mattress firm and sag resistant and at a height that enables easy transfers?
.......................................
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
2.
Is there a clear path from where participant sleeps to the bathroom for easy navigation in the dark?
.....
No
Yes
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If No: Explain: ____________________________________________________________
________________________________________________________________________
3.
Are nightlights used so that the pathway to the bathroom is visible at night?
.................................................
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
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K.
Dressing:
1.
Do you have difficulty when dressing/undressing including getting your clothes from closets/drawers, putting them on and
taking them off and doing buttons, hooks and zippers without assistance from another person? ...........................................
No
Yes
30.
___________________________________________________________
If Yes,
Describe
why completion of this activity is difficult for the participant:
_______________________________
31.
___________________________________________________________
32.
___________________________________________________________
33.
___________________________________________________________
2.
Does anyone help you dress or undress? ................................................................................................................................
No
Yes
3.
Do you require equipment when dressing or undressing? .......................................................................................................
No
Yes
34.
_________________________________________________________________
If Yes identify
type: ___________
4.
Please show me the movements you use to get your clothes, put on a shirt, pants/skirt and shoes.
Assessor: Did the participant have any difficulty completing this task?
........................................................
No
Yes
35.
If Yes, choose one and explain:
Difficulty noted
Not completed,
safety issue
36.
___________________________________________________________
37.
___________________________________________________________
38.
___________________________________________________________
5.
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
L.
Bathroom safety evaluation:
Next I will ask you about bathing and toileting, let’s go into the bathroom and I will evaluate the lighting
and the flooring in the bathing area and toilet are as well as check if there are any grab bars.
1.
Is lighting adequate (light bulbs greater than 60 watts) in the tub, toilet and shower areas?
.....................
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
2.
Are grab bars securely fastened for use while bathing in the bathing area?
...................................
None
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
3.
Are grab bars/toilet safety frame securely fastened for use with getting on and off toilet?
..........
None
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
4.
Is there a bath mat or non-skid flooring in tub/shower?
.......................................................................................
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
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5.
Are nightlights used so the bathroom is visible at night?
......................................................................................
No
Yes
If No: Explain: ____________________________________________________________
________________________________________________________________________
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Many falls that occur in the home occur in the bathroom while people are transferring on and off the
toilet and getting in and out of the shower or tub. Since these two actions are the most common cause
of fall, I am going to ask you to demonstrate how you do these activities for me.
M.
Bathing:
A. How do you usually bathe?
Sponge Bath
Whirlpool/Tub
Shower in
Tub
Shower in
Stall/Walk-in Shower
1.
Do you have difficulty when bathing including getting to and from and in and out of the bathing area, washing and
drying all parts of your body without assistance from another person?...............................................................................
No
Yes
39.
___________________________________________________________
If Yes,
Describe
why completion of this activity is difficult for you:
_____________________________________
40.
___________________________________________________________
41.
___________________________________________________________
42.
___________________________________________________________
2.
Does anyone help you bathe?...............................................................................................................................................
No
Yes
3.
Do you require equipment when bathing? ............................................................................................................................
No
Yes
43.
__________________________________________________________________
If Yes identify
type:
bath bench/seat
hand held shower
grab bars
other_____
4.
Please show me how you get in and out of your bathing area and show me how you can wash your head, back and feet.
Assessor: Did the participant have any difficulty completing this task?
........................................................
No
Yes
44.
____________________________________________________________
If Yes, choose
one and explain:
Difficulty noted
Not completed, safety issue ________________________
45.
____________________________________________________________
46.
____________________________________________________________
5.
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
N.
TOILETING:
1.
Do you have difficulty when toileting including getting to and from and on and off the toilet, cleaning yourself after
elimination and adjusting your clothing without assistance from another person?...............................................................
No
Yes
47.
___________________________________________________________
If Yes,
Describe
why completion of this activity is difficult for the participant:
_______________________________
48.
___________________________________________________________
49.
___________________________________________________________
50.
___________________________________________________________
2.
Does anyone help you toilet at all?.......................................................................................................................................
No
Yes
3.
Do you require equipment when performing this activity? ...................................................................................................
No
Yes
51.
________________________________________________________________
If Yes identify
type:
bedpan
urinal
commode
raised toilet seat
52.
_________________________________________________________________
walker
cane
wheelchair
toilet safety frame
other___________
4.
Please show me how you get on and off of your toilet.
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Assessor: Did the participant have any difficulty completing this task?
........................................................
No
Yes
53.
____________________________________________________________
If Yes, choose
one and explain:
Difficulty noted
Not completed, safety issue ________________________
54.
____________________________________________________________
55.
____________________________________________________________
5.
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
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O.
BLADDER CONTINENCE:
1.
Do you ever experience any loss of bladder control? ...........................................................................................................
No
Yes
2.
Do you use a urostomy or a catheter? ..................................................................................................................................
No
Yes
56.
....................................................................................................................................
I
f No to both questions, skip to Bowel Continence question.
57.
....................................................................................................................................
I
f Yes to either question:
•
Do have difficulty when washing yourself, disposing of soiled items, changing or adjusting your
clothing or caring for the medical device without assistance from another person? .........................
No
Yes
58.
__________________________________________________
If Yes,
Describe why completion
of this activity is difficult you:
________________________________________
59.
__________________________________________________
_________
60.
__________________________________________________
_________
61.
__________________________________________________
_________
•
Does anyone help you when you are incontinent? ............................................................................
No
Yes
•
Do you require equipment when because of your bladder incontinence?..........................................
No
Yes
62.
_________________________________________________________________
If Yes identify
type:
pads
briefs
urostomy
catheter
other__________
•
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
P.
BOWEL CONTINENCE:
1.
Do you ever experience any loss of bowel control?..............................................................................................................
No
Yes
2.
Do you use a colostomy or ileostomy?..................................................................................................................................
No
Yes
63.
....................................................................................................................................
I
f No to both questions, skip to next page.
64.
........................................................................................................................
I
f “Yes” to either question
Do have difficulty when washing yourself, disposing of soiled items, changing or
adjusting your clothing or caring for the medical device without assistance from another person? ...............................
No
Yes
65.
___________________________________________________________
If Yes,
Describe
why completion of this activity is difficult you:________________________________________
66.
___________________________________________________________
67.
___________________________________________________________
68.
___________________________________________________________
•
Does anyone help you when you are incontinent? ............................................................................
No
Yes
•
Do you require equipment when because of your bladder incontinence?..........................................
No
Yes
69.
_________________________________________________________________
If Yes identify
type:
pads
briefs
colostomy
ileostomy
other__________
•
Based on the information above and using your clinical judgment, choose the level of assistance from
another person most often required for the insured to complete this activity: (Choose only one)
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No physical assistance from another person required
Stand-by assistance from another person required – within arm’s reach for safety
Hands-on assistance from another person required – physical assist
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10.
Current Care
Q.
Do you receive personal care or assistance from any paid caregivers (including Medicare services)?.............................................
No
Yes
J.
Assessor: Below
please document any and all paid services provided to the participant.
Service Provider
(e.g. RN, CNA)
Service Provided
(e.g. skilled care, ADLs,
supervision, etc.)
Frequency per Week and Hours
per Day
(e.g., 2-3 hrs / day 7 days / wk)
Projected Duration
(e.g., Long term, 3
weeks, 3-6 weeks
)
Start Date of
Service
Hourly
Rate/
monthly fee
K.
R.
Do you receive personal care or assistance from any unpaid caregivers (including family members/friends)?...............................
No
Yes
L.
Assessor: Below
please document any and all services provided to the participant.
Unpaid Caregiver Name
and relationship
Service Provided
(check all that apply)
Frequency per Week and
Hours per Day
(e.g., 2-3 hrs/day 7 days/wk)
Projected Duration
(e.g., Long term, 3 weeks,
3-6 weeks
)
Start Date of
assistance
Does this person live
with the participant?
No
Yes
Bathing
Dressing
Transfers
Eating
Toileting
Continence
IADLs
Companionship
Supervision
Med Administration
Other____________
Does this person live
with the participant?
No
Yes
Bathing
Dressing
Transfers
Eating
Toileting
Continence
IADLs
Companionship
Supervision
Med Administration
Other____________
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Does this person live
with the participant?
No
Yes
Bathing
Dressing
Transfers
Eating
Toileting
Continence
IADLs
Companionship
Supervision
Med Administration
Other____________
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11.
Summary of Home Safety Evaluation
M.
Assessor: Take one last walk
through any rooms that you viewed and answer the following questions about the areas where the
participant spends most of his/her time. Please supply details for each “No” answer.
1.
Is flooring non-skid and firmly attached to floor?
..................................................................................................
No
Yes
If No: in which rooms:
Bathroom
Bedroom
Kitchen
Other:__________
Explain:__________________________________________________________________
________________________________________________________________________
2.
Are walkways are well lit, visible and free of obstruction and clutter?
.............................................................
No
Yes
If No: in which rooms:
Bathroom
Bedroom
Kitchen
Other:__________
Explain:__________________________________________________________________
________________________________________________________________________
3.
Are thresholds at a height no greater than ½ inch?
...............................................................................................
No
Yes
If No: in which rooms:
Bathroom
Bedroom
Kitchen
Other:__________
Explain:__________________________________________________________________
________________________________________________________________________
4.
Are scatter rugs (throw rugs) securely fastened to the floor?
..............................................................
None
No
Yes
If No: in which rooms:
Bathroom
Bedroom
Kitchen
Other:__________
Explain:__________________________________________________________________
________________________________________________________________________
5.
Are the electrical cords cleared from pathways?
....................................................................................................
No
Yes
If No: in which rooms:
Bathroom
Bedroom
Kitchen
Other:__________
Explain:__________________________________________________________________
________________________________________________________________________
6.
Are seats and chairs safe for transfers with sturdy footing and secure armrests?
.........................................
No
Yes
If No: in which rooms:
Bathroom
Bedroom
Kitchen
Other:__________
Explain:__________________________________________________________________
________________________________________________________________________
7.
Are counters/furniture secure enough to provide support if leaned upon for mobility assistance?
.........
No
Yes
If No: in which rooms:
Bathroom
Bedroom
Kitchen
Other:__________
Explain:__________________________________________________________________
________________________________________________________________________
8.
Other than was noted in the previous few pages, did the participant’s home appear to be hazard-free?
.
No
Yes
If No: Explain other safety hazards noted:
______________________________________
________________________________________________________________________
12.
Wrap up
If this is the initial in-person assessment end with:
Thank you for your participation in the Independent Living and Mobility Prevention Program. A summary of this interview
will be sent to you along with recommendations of how to maintain your independence over time and keep your home
safer. Also we will be sending the Health Promotion and Fall Prevention Tool kit mentioned at the beginning of the
interview. Additionally, a clinician will be calling you every 3 months or so to gather information from your Exercise
Progress Chart and Falls Journal which are part of the Tool kit. As part of the program, you will be asked to document in
your Exercise Progress Chart an on a weekly basis and in the Falls Journal every time you ever experience a fall or a near
fall of some kind. Thank you again for your participation!
Enter the time the
interview ends
(i.e. 2:53 PM).
Exact time:
:
am/pm
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If this is the Final in-person assessment end with:
Thank you for your participation in the Independent Living and Mobility Program. This ends the 2 year study,
we really appreciate the time you have invested in this important national program.
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13.
Clinical Summary
N.
Assessor: Complete
the Clinical Summary after you have left the Participant’s home. Please be sure to
provide an answer for each question
A.
Was there any indication that the participant is unsafe to be left alone?.................................................................................
No
Yes
If Yes, explain __________________________________________________________
___________________________________________________________________
___________________________________________________________________
B.
Was there any indication that the participant is not taking reasonable care of his/her home environment in terms of
cleanliness, neatness and minimizing clutter? ........................................................................................................................
No
Yes
If Yes, explain __________________________________________________________
___________________________________________________________________
___________________________________________________________________
C.
Was there any indication that the participant is not taking reasonable care of themselves in terms of appearance,
hygiene, and grooming? .........................................................................................................................................................
No
Yes
If Yes, explain __________________________________________________________
___________________________________________________________________
___________________________________________________________________
D.
Was anyone other than the participant present during any part of the interview? ..................................................................
No
Yes
Who:
Relationship to participant:
E.
Did anyone other than the participant answer any of the interview questions? ......................................................................
No
Yes
If Yes, explain __________________________________________________________
___________________________________________________________________
___________________________________________________________________
F.
Does the participant appear to be in immediate danger due to an unsafe home environment?...............................................
No
Yes
If Yes, explain __________________________________________________________
___________________________________________________________________
___________________________________________________________________
G.
Did you observe any non-reported safety issues (including skin breakdown, bruises, malnourishment etc…)? ....................
No
Yes
If Yes, explain __________________________________________________________
___________________________________________________________________
___________________________________________________________________
H.
Are there any other concerns or comments that you feel should be documented or explained?..............................................
No
Yes
If Yes, explain __________________________________________________________
___________________________________________________________________
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___________________________________________________________________
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14.
Field Based Observations
O.
Please use the
information you gathered during the interview to identify unmet needs that should be
addressed in the summary that will be sent to the participant.
1.
Do you feel the insured has the appropriate equipment in his/her home? ...............................................................................
Yes
No
P.
Check all
equipment/safety devices that the insured does not have, but would benefit from, to
remain safely in his/ her present location: For each piece of equipment noted, indicate
why it is needed below:
Straight Cane
Hospital Bed
Commode
Multi-pronged Cane
Tub rail (tub)
Raised Toilet Seat
Walker
Bath/shower Stool
Toilet Safety Frame
1
Wheelchair
Shower bench with back
Medical Alert System
Electric Scooter
Hand Held Shower
2
Stair Lift
Electric Recliner
Grab Bars in shower/tub
Other: ________________
Type of Equipment
Reason recommended
2.
Do you feel the insured has the appropriate level, intensity and duration of services? ..........................................................
Yes
No
Q.
If No, complete
the table below. In the table below, check the type of care you would recommend for
this insured and provide information on frequency and duration.
Recommended Service
Recommended Frequency
Recommended Duration
Home Health Aide/Personal Care Attendant
____hrs/day ____d/wk
Homemaker/Companion
____hrs/day ____d/wk
Physical/Occupational/Speech Therapy
____hrs/day ____d/wk
Skilled Nurse
____hrs/day ____d/wk
Medical Social Worker
____hrs/day ____d/wk
Meals on Wheels/Nutritional Services
____meals/wk
Pharmaceutical Care
Transportation
Other_____________________
Other_____________________
Why are these services being recommended?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
1
Minimum requirement: 3 inches between toilet and sink/tub and no shelves above toilet with legs going to floor
2
Due to liability, typically Hand Held Showers will not be installed by the Medical Equipment Vendors
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~ PLEASE FAX IMMEDIATELY TO ----------------- WHEN COMPLETED! THANK YOU ~
Assessor signature:
Date of interview:
| File Type | application/pdf |
| File Title | Microsoft Word - Appendix C.doc |
| Author | jmiller |
| File Modified | 2006-02-01 |
| File Created | 2006-02-01 |