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pdfADMISSION/INTAKE QUESTIONNAIRE
I. Administrative Information
Office Staff: Please complete this information before providing this questionnaire
to the patient or to whomever is helping them.
A.1
Current Date
A.2
Names and National Provider Identification Codes (NPI) for therapists billing separately
Please enter the names and NPIs of therapists treating this patient in this clinic who bill Medicare separately. Each
therapist who bills Medicare separately must complete their own separate “Provider Information” sections.
|___|___| / |___|___| / |___|___|___|___|
MM
DD
YYYY
FOR OFFICE USE ONLY
Therapist Name
Therapist NPI
A.2.a
___________________________________
A.3.a
|___|___|___|___|___|___|___|___|___|___|
A.2.b
___________________________________
A.3.b
|___|___|___|___|___|___|___|___|___|___||
A.2.c
___________________________________
A.3.c
|___|___|___|___|___|___|___|___|___|___|
A.2.d
___________________________________
A.3.d
|___|___|___|___|___|___|___|___|___|___|
A.4
Patient’s Medicare Health Insurance Claim Number
A.5
Does the patient need someone to assist them to complete the form, or answer for them?
There are several items in this questionnaire intended to be reported by patients. However, some patients may
need assistance to fill out the form, and others may need someone to fill the form out for them.
A.5a
Based on your knowledge of the patient or conversations you have had with him or her, please indicate
whether the patient may need assistance completing the form or needs to have someone else complete
the form for them. Please check all that apply.
1. The patient cannot read English or Spanish.
2. The patient has low vision or blindness.
3. The patient cannot write their own responses on the
form (e.g., upper limb impairment).
4. The patent has difficulty understanding instructions.
5. The patient cannot concentrate for 15 minutes.
6. The patient cannot give correct/accurate answers to
questions about their health.
7. Another reason:
_________________________________
|___|___|___|___|___|___|___|___|___|___|___|___|
8. The patient does not need any assistance and
can complete the questionnaire themself.
If a patient meets any of the above conditions, please choose an assistant or proxy to help the patient answer the
questionnaire from the following list:
1. Family member or friend who came to the appointment with the patient
2. Treating therapist
3. Other office staff (ONLY if the patient appears to need an assistant to write down answers on the form, NOT if
they appear to need a proxy to answer for them)
Please go in order down the list to choose an assistant or proxy. For example, if someone who came with the
patient cannot help, please have the treating therapist help the patient with the questionnaire.
A.5b Who completed this form?
Patient
Proxy/Assistant:
Family Member
Companion Not Family
Therapist
Other Office/Practice Staff
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average 20 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
2D Provider Barcode
Page 1 of 17 Rev. 4/14/2010
ADMISSION/INTAKE QUESTIONNAIRE
II. Patient Information
Patients: Please complete this form before meeting with your therapist.
B.1a
First Name
B.2
Gender
B.1b
Middle Initial
Male
Female
B.3
B.1c
Last Name
Birth Date |___|___| / |___|___| / |___|___|___|___|
Check all
that apply.
MM
Race/Ethnicity (Check all that apply.)
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Hispanic or Latino
B.5
Education (Check one box)
C.1
Primary Condition
B.4
DD
YYYY
e. Native Hawaiian or Pacific Islander
f. White
g. Unknown
Less than high school diploma
Some college – no degree
High school graduate
College or more
What are the main health conditions for which/reasons why you are receiving therapy? Check all
that apply.
Check all that apply.
Problems of the muscles, ligaments, joints and/or bones
C.2
C.3
a.
b.
c.
d.
e.
General
Head and/or neck
Back and/or pelvis
Ribs and/or collarbone
Hip
f.
g.
h.
i.
Knee, leg, and/or foot
Shoulder
Elbow
Wrist, hand, and/or fingers
p.
q.
r.
s.
t.
u.
Wound and/or skin problem
Mental health condition
Cancer
Communication, voice, or speech disorder
Swallowing disorder
Other condition(s)
Other problems:
j.
k.
l.
m.
n.
o.
General weakness
Problem with walking or balance
Problem of the heart and/or blood vessels
Problem of the lungs and/or breathing
Problem of the nervous system
Problems with eyes, inner ear, or ears
How long ago did the health conditions/reasons for which you were being treated begin?
Within a week
Within the last 3 months
Within the last month
More than 3 months ago
Surgical Status
a.
Indicate the number of surgeries you have had in the past for the main condition for which/reason
why you are receiving therapy.
1
2
3
4 or more
None
b.
When was your most recent surgery for the condition for which you are receiving therapy?
Within the last week
Within the last 3 months
Within the last month
More than 3 months ago
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ADMISSION/INTAKE QUESTIONNAIRE
II. Patient Information (cont.)
C.5
Other Medical Conditions
Has a doctor or other health professional ever told you that you have any of the following
conditions? Please check all that apply.
a. Arthritis (rheumatoid and/or osteoarthritis)
b. Osteoporosis
c. Asthma
d. Chronic obstructive pulmonary disease (COPD), acquired respiratory distress syndrome
(ARDS), emphysema, or asthma
e. Chest pain from your heart (such as angina, irregular heart rhythm, or valve problems)
f. Difficulty breathing or swelling in your legs because of your heart (such as congestive heart
failure)
g. Heart attack (myocardial infarct)
h. Multiple sclerosis (MS), Parkinson’s, or any other neurological condition
i. Stroke or transischemic attack (TIA)
j. Peripheral vascular condition, peripheral artery disease (PAD), or blood disorders
k. Diabetes
l. Ulcer, hernia, reflux, or any other upper gastrointestinal condition
m. Depression
n. Anxiety or panic disorders
o. Cataracts, glaucoma, macular degeneration, loss of visual field, or any other visual
impairment
p. Spine/back problem, spinal stenosis, severe chronic back pain, or any other degenerative
disc condition
q. High blood pressure
r. Headaches
s. Kidney, bladder, prostate, or urination problems
t. Allergies
u. Incontinence
v. Hepatitis
w. HIV/AIDS
x. Prostheses or implants
y. Sleep dysfunction
z. Cancer
aa. Other disorders: Please write in_________________
Check all that apply.
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ADMISSION/INTAKE QUESTIONNAIRE
II. Patient Information (cont.)
E.
Pain or Hurting
E.1
Pain Presence or Hurting
Have you had pain or hurting at any time during the last 7
days? If “no,” please skip to the next page.
Yes
No
Don’t know
Pain or Hurting Severity (Check one box.)
Please rate your worst pain during the last 7 days from 0 to 10, with 0 being no pain and 10 being the
worst pain you can imagine.
0
1
2
3
4
5
6
7
8
9
10
No
Moderate
Worst
Pain
Pain
Pain
E.3 Please describe your pain or hurting. (Check all that apply.)
Check all
that apply.
E.2
E.4
a. Constant
e. Burning
i. Ache/Throb
m. Tightness
b. Intermittent
f. Pinching
j. Stabbing
n. Stiffness
c. Sharp
g. Numbness
k. Pulling
d. Dull
h. Tingling
l. Cramping
o. Other: Please
write in
____________
Pain/Hurting Location
R
L
L
R
Please mark with an X the area(s) of
your body where you have pain or hurting.
E.5
Pain/Hurting Effect on Sleep
(Check one box.)
During the past 2 days, has pain made it hard
for you to sleep?
No
Yes
Don’t know
2D Provider Barcode
E.6
Pain/Hurting Effect on Activities
(Check one box.)
During the past 2 days, have you limited your
activities because of pain?
No
Yes
Don’t know
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ADMISSION/INTAKE QUESTIONNAIRE
II. Patient Information (cont.)
Basic Mobility
Do you have difficulty with getting around (mobility), either walking or in a wheelchair?
Yes
Î If “yes,” please answer the rest of the questions on this page.
No
Î If “no,” please skip to the next page.
How much DIFFICULTY do you currently have…
(If you have not done an activity recently, how much difficulty do you
A
think you would have if you tried?)
Unable A Lot Little
a. Moving from sitting at the side of the bed to lying down on your back?
b. Moving up in bed (e.g., reposition self)?
c. Standing for at least one minute?
d. Sitting down in an armless straight chair (e.g., dining room chair)?
e. Standing up from an armless straight chair (e.g., dining room chair)?
f. Getting into and out of a car/taxi (sedan)?
g. Cleaning up spills on the floor (e.g., with a rag or mop)?
F.1
h. Walking around one floor of your home, taking into consideration
thresholds, doors, furniture, and a variety of floor coverings?
i. Going up and down a flight of stairs inside, using a handrail?
j. Bending over from a standing position to pick up a piece of clothing from
the floor without holding onto anything?
k. Walking several blocks?
l. Walking up and down steep unpaved inclines (e.g., steep gravel
driveway)?
m. Taking a 1-mile brisk walk, without stopping to rest?
n. Carrying something in both arms while climbing a flight of stairs (e.g.,
laundry basket)?
How much HELP from another person do you currently need…
(If you have not done an activity recently, how much help do you
think you would need if you tried?)
o. Moving to and from a bed to a chair (including a wheelchair)?
p. Moving to and from a toilet?
q. Stepping into and out of a shower?
None
A Lot
A
Little
None
A Lot
A
Little
None
Unable
Do you also use a wheelchair to get around?
Yes
Î If “yes,” please answer the rest of the questions on this page.
No
Î If “no,” please skip to the next page.
Without help from another person, when you are using your
wheelchair, how much DIFFICULTY do you currently have… (If
you have not done an activity recently, how much help do you think
you would need if you tried?)
Unable
a. Moving around within one room, including making turns in a wheelchair?
b. Reaching for a high object, using a wheelchair?
c. Opening a door away from a wheelchair?
d. Opening a door toward a wheelchair?
F.2
e. Transferring between a wheelchair and other seating surfaces, such as a
chair or bed?
f. Propelling/driving a wheelchair several blocks?
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ADMISSION/INTAKE QUESTIONNAIRE
II. Patient Information (cont.)
Everyday Activities
Do you have difficulty with engaging in everday activities?
Yes
Î If “yes,” please answer the rest of the questions on this page.
No
Î If “no,” please skip to the next page.
F.3
How much HELP do you currently need…
(If you have not done an activity recently, how much help do you
think you would need if you tried?)
a. Taking care of your personal grooming such as brushing teeth, combing
hair, etc.?
b. Bathing yourself (including washing, rinsing, drying the body)?
How much DIFFICULTY do you currently have…
(If you have not done an activity recently, how much difficulty do you
think you would have if you tried?)
c. Inserting a key in a lock and turning it to unlock the door?
d.
e.
f.
g.
h.
Picking up thin, flat objects from a table (e.g., coins, post card, envelope)?
Putting on and taking off a shirt or blouse?
Putting on and taking off socks?
Opening small containers like aspirin or vitamins (regular screw tops)?
Picking up a gallon carton of milk with one hand and setting it on the
table?
i. Removing stiff plastic packaging using hands and scissors?
j. Tying shoes?
k. Replacing or tightening small parts using only your hands (e.g., screws)?
l. Unscrewing the lid off a previously unopened jar without using devices?
m. Washing indoor windows?
n. Pounding a nail in straight with a hammer to hang a picture?
o. Lifting 25 pounds from the ground to a table?
p. Cutting your toenails?
2D Provider Barcode
Unable
A Lot
A
Little
Unable
A Lot
A
Little
None
None
Page 6 of 17 Rev. 4/14/2010
ADMISSION/INTAKE QUESTIONNAIRE
II. Patient Information (cont.)
Life Skills
Do you have difficulty with communicating, remembering, organizing, or planning in your daily life?
Yes
Î If “yes,” please answer the rest of the questions on this page.
No
Î If “no,” please go to the next page.
How much DIFFICULTY do you currently have…
(If you have not done an activity recently, how much difficulty do you
A
think you would have if you tried?)
Unable A Lot Little None
F.4
a. Understanding instructions involving several steps (e.g., how to prepare a
meal or following directions)?
b. Following/understanding a 10- to 15-minute speech or presentation (e.g.,
lesson at a place of worship, guest lecture).
c. Answering yes/no questions about basic needs (e.g., “Do you need to use
the restroom?” “Are you in pain?”)
d. Making yourself understood to other people during ordinary
conversations?
e. Telling someone important information about yourself in case of
emergency?
f. Explaining how to do something involving several steps to another
person?
g. Reading and following complex instructions (e.g., directions to operate a
new appliance or for a new medication)?
h. Telling others your basic needs (e.g., need to use the restroom, have a
drink of water or request help)?
i. Planning for and keeping appointments that are not part of your weekly
routine (e.g., a therapy or doctor appointment, or a social gathering with
friends and family)?
j. Reading simple material (e.g., a menu or the TV or radio guide)?
k. Filling out a long form (e.g., insurance form or an application for
services)?
l. Writing down a short message or note?
m. Getting to know new people?
n. Remembering where things were placed or put away (e.g., keys)?
o. Remembering personal information (e.g., medical history, important
events)?
p. Keeping track of time (e.g., using a clock)?
q. Putting together a shopping list of 10 to 15 items?
r. Remembering a list of 4 or 5 errands without writing it down?
s. Taking care of complicated tasks like managing a checking account or
getting appliances fixed?
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ADMISSION/INTAKE QUESTIONNAIRE
II. Patient Information (cont.)
G.
Participation
G.1 Taking into account any help or
services that are unavailable to
you, how much are you currently
limited in…
a. Keeping your home clean and fixed
up?
b. Providing personal care to yourself?
c. Getting groceries or other things for
your home?
Not At All
A Little
Somewhat
Very Much
Extremely
Limited
Don’t Do
This/Not
Applicable
G.2 How much are you currently
limited in…
a. Doing recreational or leisure
activities?
b. Going to movies, plays, concerts,
sporting events, museums, or similar
activities?
G.3
Not At All
A Little
Somewhat
Very Much
Extremely
Limited
Think about how you currently socialize with others, like going out or visiting with family and friends.
Which of the following best describes you? (Check one box.)
I do not have any difficulty doing things socially.
I maintain my usual pattern of social activities, despite some difficulties.
I am somewhat restricted in the amount or type of social activities I do.
I am very restricted in the amount or type of social activities I do.
I do not see family or friends, and I only see those who provide care to me.
H.
Additional Questions
Living Situation – What is your current living situation? (Check all that apply.)
d. I live with paid help
a. I live with my spouse/significant other
b. I live with adult children/other family or friends
e. I live alone
f. I live in a nursing home
c. I live with other people (not family or friends)
Check all
that apply.
H.1
H.2
History of Falls
Yes
No
Don’t know
a.
Have you had two or more falls in the past year?
b.
Have you had any fall with injury in the past year?
H.3
Feeling Sad?
During the past 2 weeks, how often would you say, “I feel sad?”
Never
Rarely
Sometimes
Often
Always
Don’t know
Confidence
Thinking about all the activities you like to do, how much confidence do you feel today about your overall ability in
doing them?
H.4
None
Some
A lot
Complete
Don’t know
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE!
2D Provider Barcode
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ADMISSION/INTAKE QUESTIONNAIRE
III. Provider Information
Providers, please complete by the end of your therapy session.
A. Primary Reason for Therapy
Please indicate the primary body function(s), body structure(s), and activity & participation reason(s) for which you are treating
this patient using the categories below. Check all primary reasons for therapy that apply.
A.1 Body Functions (Check at least one)
a. Global Mental Functions (consciousness, orientation,
intellectual function, energy & drive, sleep,
temperament, personality)
b. Specific Mental Functions (attention, memory,
psychomotor, emotional, perceptual, higher level
cognition, sequencing of complex tasks, calculation,
mental functions of language)
c. Seeing & Related Functions
d. Hearing
e. Vestibular Functions
f. Proprioceptive & Touch Functons
g. Other Sensory Functions (taste, smell)
h. Pain
i. Voice & Speech Functions (articulation, speech,
fluency & rhythm, alternative vocalization)
j. Functions of the Cardiovascular System
k. Functions of the Immunological & Hematological
Systems
l. Functions of the Respiratory System
m. Functions of the Digestive System
n. Functions Related to Metabolism & Endocrine System
o. Urinary Functions
p. Genital & Reproductive Functions
q. Functions of the Joints & Bones
r. Muscle Functions (muscle power, tone, endurance)
s. Movement Functions (motor reflexes, involuntary
movements, control of movements, gait patterns,
neuromuscular functions)
t. Functions of the Skin
u. Functions of the Hair & Nails
A.2 Body Structures (Check at least one)
Structures Related to Movement
a. General/No Specific Body Location
b. Head
c. Cervical Spine
d. Thoracic Spine
e. Lumbar Spine
f. Pelvic Girdle
L: Left Side; R: Right Side
L R
g. Hip
h. Thigh
i. Knee
j. Calf
k. Foot/Ankle
l. Toes
m. Shoulder
n. Arm
o. Elbow
p. Wrist
q. Hand
r. Fingers
Structures Involved in Voice & Speech
s. Nose
t. Mouth
u. Tongue
v. Pharynx
w. Larynx
Other Structures
x. Eye & Related Structures
y. Ear & Related Structures
z. Structures of the Central Nervous System
aa. Structures of the Peripheral Nervous System
bb. Structures of the Cardiovascular, Immunological, &
Respiratory Systems
cc. Structures Related to the Digestive, Metabolic, &
Endocrine Systems
dd. Structures Related to the Genitourinary &
Reproductive Systems
ee. Skin & Related Structures
A.3 Activities and Participation
(Check at least one)
a. Purposeful Sensory Experiences (watching,
listening)
b. Basic Learning (copying, rehearsing, learning to
read, write, acquiring skills)
c. Applying Knowledge (focusing attention, thinking,
reading, writing, calculating, solving problems,
making decisions)
d. General Tasks & Demands (simple and multiple
tasks, carrying out daily routine, handling stress)
e. Communication: Receiving (spoken, nonverbal,
sign language, written)
f. Communication: Producing (speaking, nonverbal,
sign language, writing)
g. Conversation & Use of Communication Devices
(conversation, discussion, using devices and
techniques)
h. Changing & Maintaining Body Position
i. Carrying, Moving, & Handling Objects
j. Walking & Moving
k. Moving Around Using Transportation
l. Self Care (washing oneself, toileting, dressing,
eating, drinking)
m. Acquisition of Necessities (a place to live, goods and
services)
n. Household Tasks (preparing meals, doing
housework)
o. Caring for Household Objects & Assisting Others
p. General Interpersonal Interactions
q. Particular Interpersonal Interactions (relating with
strangers, formal and informal relationships, family
and intimate relationships)
r. Education
s. Work & Employment
t. Economic Life
u. Community, Social, & Civic Life
Check all that
apply.
A.4 Why is the patient receiving therapy services covered by Medicare Part B?
a.
b.
c.
d.
e.
f.
Continuation of therapy services provided under Medicare Part A
Change in physical functional status
Change in cognitive status (incl. emergence from coma, persistent vegetative state, etc.)
Change in medical status
Change in or loss of caregiver
Other (specify) ________________________________
2D Provider Barcode
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ADMISSION/INTAKE QUESTIONNAIRE
Form ID
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III. Provider Information (cont.)
Providers, please complete by the end of your therapy session.
B. Primary and Secondary Medical Diagnoses
Based on available medical information, please indicate the patient’s primary (1ary) and secondary (2ary) medical conditions.
The primary diagnosis should be related to the reason for therapy. Please check all that apply.
B.1 Musculoskeletal
1ary 2ary
a. Pain Syndrome (fibromyalgia, polymyalgia,
etc.)
b. Pain, Not Pain Syndrome
c. Osteoarthritis
d. Rheumatoid Arthritis
e. TMJ Disorder
f. Fracture
g. Sprain/Strain
h. Osteoporosis
i. Herniated Disc
j. Spinal Stenosis
k. Scoliosis
l. Torticolis
m. Contusion
n. Joint Replacement
o. Amputation
p. Bursitis
q. Tendonitis
r. Internal Derangement of Joint
s. Tendon Rupture
t. Nerve Entrapment
u. Contracture
v. Other __________
B.2 Circulatory
1ary 2ary
a. TIA
b. Stroke
c. Atrial Fibrillation & Other Dysrhythmia
(bradycardia, tachydardia)
d. Coronary Artery Disease (angina, myocardial
infarction)
e. Deep Vein Thrombosis (DVT)
f. Heart Failure (including pulmonary edema)
g. Hypertension
h. Peripheral Vascular Disease/Peripheral Arterial
Disease
i. Other __________
B.3 Lymphatic System
1ary 2ary
a. Lymphedema
b. Other __________
B.4 Pulmonary/Respiratory System
1ary 2ary
a. Asthma
b. Bronchitis
c. Pneumonia
d. Chronic Obstructive Pulmonary Disease (COPD)
e. Cystic Fibrosis
f. Other __________
B.5 Integumentary System
1ary 2ary
a. Skin Ulcer/Wound
b. Burn
c. Other __________
2D Provider Barcode
B.6 Genitourinary System
1ary 2ary
a End Stage Renal Disease (ESRD)
b. Incontinence
c. Pelvic Pain
d. Other __________
B.7 Mental Health
1ary 2ary
a. Anxiety Disorder
b. Depression
c. Bipolar Disease
d. Attention Disorder
e. Schizophrenia
f. Alzheimer’s Disease
g. Other __________
B.8 Cancer/Other Neoplasms
1ary2ary
a. Please Specify
B.9 Metabolic System
1ary 2ary
a. Diabetes Mellitus
b. Obesity
c. Other __________
B.10 Generalized Weakness
1ary 2ary
a. Generalized Weakness
B.11 Infectious Diseases
1ary 2ary
a. Please Specify
B.12 HIV
1ary 2ary
a. HIV
B.13 Gastrointestinal Disorders
1ary 2ary
a. Please Specify
B.14 Immune Disorders
1ary 2ary
a. Immune Disorders
B.15 Anemias/Other Hematological
Disorders
1ary 2ary
a. Anemia
b. Other _________________
B.16 Congenital Abnormalities
1ary 2ary
a. Musculoskeletal Congenital Deformities/
Anomalies
b. Neurological Congenital/Developmental
Anomalies
c. Other _________________
B.17 Neurological Conditions
1ary 2ary
a. Specific Diseases of Central Nervous System
(CNS)
b. Cranial Neuralgia
c. Cranial Nerve Injury
d. Seizure Disorder
e. Paralysis
f. Peripheral Nervous System Disorder (including
neuropathy)
g. Complex Regional Syndrome
h. Vertigo
i. Multiple Sclerosis
j. Parkinson’s
k. Huntington’s Disease
l. Head Injury
m. Traumatic Brain Injury
n. Non-Traumatic Brain Injury
o. Encephalopathy
p. Retinopathy
q. Guillain-Barré Syndrome
r. Other __________
B.18 Cognition/Judgement
1ary 2ary
a. Executive Function Disorder
b. Memory Impairment
c. Pragmatics Disorder
d. Dementia
e. Other _________________
B.19 Communication, Voice, or Speech
Disorder
1ary 2ary
a. Aphasia
b. Apraxia of Speech
c. Reading or Writing Dysfunction
d. Voice Disorder (Dysphonia)
e. Speech Disorder
f. Cognitive-Communication Disorder
g. Other __________
B.20 Swallowing Disorder
1ary 2ary
a. Dysphagia
B.21 Sensory Disorders/Gait or Balance
Disorder
1ary 2ary
a. Hearing Impairment
b. Vision Impairment
c. Gait or Balance Disorder
d. Other _________________
B.22 Other Condition
1ary 2ary
a. Please Specify _________________
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ADMISSION/INTAKE QUESTIONNAIRE
Form ID
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III. Provider Information (cont.)
C. Supplemental
Conditions/Impairments
C.1a Does the patient have any vision impairments?
C.2a Does the patient have any hearing impairments?
C.3a Does the patient have any signs or symptoms of a possible
C.4a
C.5a
C.6a
C.7a
swallowing disorder?
Does the patient have any problems with memory,
attention, problem solving, planning, organizing or
judgment?
Does the patient have any signs or symptoms of a possible
communication impairment?
Does this patient have one or more unhealed pressure
ulcers at stage 2 or higher or unstageable?
Does the patient have any impairments with bladder or
bowel management (e.g., use of a device or
incontinence)?
Yes
No
Don’t Know
If “Yes,” complete…
C.4b & C.4c on page 12
C.5b–C.5d on page 12
C.6b on page 13
C.7b–C.7d on page 13
C.1b on page 11
C.2b on page 11
C.3b on page 11
If you answered “No” or “Don’t Know” to all of items C.1a–C.7a above, you are done with this
assessment instrument and may skip all remaining items.
C.1
Vision
Answer only if you answered “Yes” to C.1a (Does the patient have any vision impairments?)
C.1b
Describe the patient’s ability to see
in adequate light (with glasses or
other visual appliances)
C.2
Hearing
Adequate: Sees fine detail, including regular print in newspapers/books
Mild to Moderately Impaired: Can identify objects; may see large print
Severely Impaired: No vision or object identification questionable
Answer only if you answered “Yes” to C.2a (Does the patient have any hearing impairments?)
C.2b
Describe the patient’s ability to
hear (with hearing aid or hearing
appliance, if normally used)
Adequate: Hears normal conversation and TV without difficulty
Mild to Moderately Impaired: Difficulty hearing in some environments or
speaker may need to increase volume or speak distinctly
Severely Impaired: Absence of useful hearing
C.3
Swallowing
C.3b
What signs and symptoms of a
swallowing disorder does the
patient have?
2D Provider Barcode
Check all that apply.
Answer only if you answered “Yes” to C.3a (Does the patient have any signs or symptoms of a possible swallowing
disorder?)
1. History of dysphagia/aspiration pneumonia
2. Complaints of difficulty or pain with swallowing
3. Coughing or choking during meals or when swallowing
medications
4. Holding food in mouth/cheeks or residual food in mouth after
meals
5. Loss of liquids/solids from mouth when eating or drinking
6. NPO: intake not by mouth
7. Other (specify) _________________________
Page 11 of 17 Rev. 4/14/2010
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III. Provider Information (cont.)
C.4
Cognitive Status
C.4b
Please indicate all of the following
that the patient is able to recall:
Check all that apply.
Answer only if you answered “Yes” to C.4a (Does the patient have any problems with memory, attention, problem solving,
planning, organizing or judgment?)
1. Current season
2. Location of own room (nursing home only)
3. Staff names and faces
4. That s/he is in a hospital, nursing home, clinic, office, or home
5. None of the above
Mildly impaired: Demonstrates some difficulty with one or more of these
C.4c
Please describe the patient’s
problems with memory, attention,
problem solving, planning,
organizing, or judgment.
cognitive abilities.
Moderately impaired: Demonstrates marked difficulty with one or more of
these cognitive abilities.
Severely impaired: Demonstrates extreme difficulty with one or more of
these cognitive abilities.
C.5
Communication
Answer only if you answered “Yes” to C.5a (Does the patient have any signs or symptoms of a possible communication
impairment?)
Mildly impaired: Demonstrates some difficulty with comprehension and/or
expression but is able to functionally communicate most of the time.
C.5b
Please describe the patient’s
problems with communication.
Moderately impaired: Demonstrates marked difficulty with comprehension
and/or expression that noticeably interferes with functional communication.
Severely impaired: Demonstrates extreme difficulty with comprehension
and/or expression with little-to-no functional communication.
C.5c
Please describe the patient’s ability
to understanding verbal content
(excluding language barriers).
C.5d
Please describe the patient’s ability
to express ideas and wants.
2D Provider Barcode
Understands: Clear comprehension without cues or repetitions.
Usually Understands: Understands most conversations, but misses some
part/intent of message. Requires cues at times to understand.
Sometimes Understands: Understands only basic conversations or simple,
direct phrases. Frequently requires cues to understand.
Rarely/Never Understands.
Expresses complex messages without difficulty and with speech that is clear
and easy to understand.
Exhibits some difficulty with expressing needs and ideas (e.g., some words or
finishing thoughts) or speech is not clear.
Frequently exhibits difficulty with expressing needs and ideas.
Rarely/Never expresses self or speech is very difficult to understand.
Page 12 of 17 Rev. 4/14/2010
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III. Provider Information (cont.)
Pressure Ulcers
C.6
Answer only if you answered “Yes” to C.6a (Does this patient have one or more unhealed pressure ulcers at stage 2 or
higher, or unstageable?)
C.6b Do these pressure ulcers interfere
Yes
No
Don’t Know
with your therapy treatments?
Incontinence
C.7
Answer only if you answered “Yes” to C.7a (Does the patient have any impairments with bladder or bowel management
[e.g., use of a device or incontinence]?)
C.7b Does the incontinence interfere
Yes
No
Don’t Know
with your therapy treatments?
C.7c Bladder
C.7c&d
Please Indicate the frequency
of the patient’s bladder and
bowel incontinence.
2D Provider Barcode
C.7d Bowel
Stress Incontinence Only
Incontinent Less Than Daily
Incontinent Daily
Always Incontinent
No Urine/Bowel Output
Not Applicable
Page 13 of 17 Rev. 4/14/2010
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III. Provider Information (cont.)
D.
Supplemental Swallowing, Cognition, & Communication Function
Are you treating or evaluating this patient for any of the following reasons?
D.1a
Signs or symptoms of a possible swallowing disorder?
D.1b
Difficulty with communicating in daily life?
D.1c
Difficulty with remembering, organizing, or attending in daily
life?
Yes
No
If “Yes,” complete…
D.2 on page 14
D.3–D.6 on pages 14 & 15
D.7–D. 9 on page 16
If you answered “No” to all of items D.1a–D.1c above, you are done with this assessment instrument
and may skip all remaining items.
Swallowing Function
D.2
Answer only if you answered “Yes” to D.1a (Signs or symptoms of a possible swallowing disorder?)
For safety and maximal nutritional intake, the patient requires:
Liquid Diet Modification: Thickened liquids (e.g., consistency of
syrup, honey, or pudding)
Solid Diet Modification: Cooked until soft; chopped, ground,
mashed; or pureed
Maximal Cueing: Multiple cues that are obvious to nonclinicians,
including any combination of auditory, visual, pictorial, tactile, or
written cues
D.2a
Diet Modification
Both Liquids & Solids
Either Liquids or Solids
None
D.2b
Level of Cueing or
Assistance
Maximal
Minimal
None
Minimal Cueing: Subtle and only one type of cueing
D.3–D.6
Communication Function
Answer only if you answered “Yes” to D.1b (Difficulty with communicating in daily life?)
In Questions D.3 through D.6, please use the following definitions for the frequency with which the patient can perform the
indicated activity and for level of assistance:
Frequency Performing Activity
Level of Assistance
D.3
Never:
Unable
Rarely:
Sometimes:
Usually or Always:
Less than 20% of the time
Between 20% and 49% of the time
At least 50% of the time
Without Assistance:
Patient performance without cueing, external guidance, assistive
device, or other compensatory augmentative intervention
Patient performance with cueing, external guidance, assistive
device, or other compensatory augmentative intervention
With Assistance:
Language Comprehension
The patient comprehends:
Basic Information: Simple directions; simple
yes/no questions; simple words or phrases
Complex Information: Complex
sentences/directions/messages;
conversations about routine daily activities
Basic Information
Never
Rarely
Sometimes
Usually or Always
2D Provider Barcode
Complex Information
D.3a
Without
Assistance
D.3b
With
Assistance
D.3c
Without
Assistance
D.3d
With
Assistance
Page 14 of 17 Rev. 4/14/2010
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III. Provider Information (cont.)
D.4
Language Expression
The patient conveys:
Basic Information: Simple directions; simple
yes/no questions; simple words or phrases
Complex Information: Complex
sentences/directions/messages;
conversations about routine daily activities
Basic Information
Never
Rarely
Sometimes
Usually or Always
D.5
D.4b
With
Assistance
D.4c
Without
Assistance
D.4d
With
Assistance
Motor Speech Production
The patient’s speech is:
Intelligible in Short Utterances: Short
consonant-vowel combinations; automatic
words; simple words or predictable phrases
Intelligible in Conversation: Long
utterances; low predictability sentences;
communication in vocational, avocational,
and social activities
Intelligible in Short
Utterances
Never
Rarely
Sometimes
Usually or Always
D.6
Complex Information
D.4a
Without
Assistance
Intelligible in
Conversation
D.5a
Without
Assistance
D.5b
With
Assistance
D.5c
Without
Assistance
D.5d
With
Assistance
Voice
The patient’s voice is functional in the
following types of activities:
Low Vocal Demand: Speaking softly;
speaking in quiet environments; talking for
short periods of time
High Vocal Demand: Speaking loudly;
speaking in noisy environments; talking for
extended periods of time
Low Vocal Demand
Never
Rarely
Sometimes
Usually or Always
2D Provider Barcode
High Vocal Demand
D.6a
Without
Assistance
D.6b
With
Assistance
D.6c
Without
Assistance
D.6d
With
Assistance
Page 15 of 17 Rev. 4/14/2010
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III. Provider Information (cont.)
D.7–D.9
Cognitive Function
Answer only if you answered “Yes” to D.1c (Difficulty with remembering, organizing, or attending in daily life?)
In Questions D.7 through D.9, please use the following definitions for the frequency with which the patient can perform the
indicated activity and for level of assistance:
Frequency Performing Activity
Level of Assistance
D.7
Never:
Rarely:
Unable
Less than 20% of the time
Sometimes:
Usually or Always:
Between 20% and 49% of the time
At least 50% of the time
Without Assistance:
Patient performance without cueing, external guidance, assistive
device, or other compensatory augmentative intervention
Patient performance with cueing, external guidance, assistive
device, or other compensatory augmentative intervention
With Assistance:
Problem Solving
The patient solves:
Simple Problems: Following schedules;
requesting assistance; using a call bell;
identifying basic wants/needs; preparing a
simple cold meal
Complex problems: Working on a
computer; managing personal, medical, and
financial affairs; preparing a complex hot
meal; grocery shopping; route finding and
map reading
D.8
Never
Rarely
Sometimes
Usually or Always
Complex Problems
D.7b
With
Assistance
D.7c
Without
Assistance
D.7d
With
Assistance
Memory
The patient recalls:
Basic Information: Personal information
(e.g., family members, biographical
information, physical location); schedules;
names of familiar staff; location of therapy
area
Complex Information: Complex and novel
information (e.g., carry out multiple-step
activities, follow a plan); anticipate future
events (e.g., keeping appointments)
D.9
Simple Problems
D.7a
Without
Assistance
Basic Information
Never
Rarely
Sometimes
Usually or Always
Complex Information
D.8a
Without
Assistance
D.8b
With
Assistance
D.8c
Without
Assistance
D.8d
With
Assistance
Attention
The patient maintains attention for:
Simple Activities: Following simple
directions; reading environmental signs;
eating a meal; completing personal hygiene;
dressing
Complex Activities: Watching a news
program; reading a book; planning and
preparing a meal; managing one’s own
medical, financial, and personal affairs
2D Provider Barcode
Simple Activities
Never
Rarely
Sometimes
Usually or Always
Complex Activities
D.9a
Without
Assistance
D.9b
With
Assistance
D.9c
Without
Assistance
D.9d
With
Assistance
Page 16 of 17 Rev. 4/14/2010
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IV. Other Useful Information
A.
Is there other useful information about this patient that you want to add?
V. Feedback
A.
Notes
Thank you for your participation in this important project. So that we may improve the form for future use, please comment on
any areas of concern or things you would change about the form.
2D Provider Barcode
Page 17 of 17 Rev. 4/14/2010
| File Type | application/pdf |
| Author | Edward M. Drozd |
| File Modified | 2010-04-14 |
| File Created | 2010-04-14 |