Assessment Form - Alternative - CDQ

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Email Address * First Name * Last Name * Gender Birth Date

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Apply For Nurse or Caregiver?

Apply For Nurse Apply For Caregiver

- Step 1 of 3

Patient Informations

Patient Name *

First

Middle

Last

Date of Birth *

Gender *

Male
Female

Nationality

Patient Address *

Address Line 1

City

State / Province / Region

Country

QID Number

Patient Contact Number *

Emergency Contact Name *

First

Last

Emergency Contact Number *

Relationship of Guarantor to Patient

Living Situation

Living Place *

Villa
Apartment
House
Other

Other Please explain

Lives Alone

Yes
No

Identify all individuals living in the home

Hospitalisation

Hospital Name

Hospital Address

Address Line 1

City

State / Province / Region

Country

Primary Doctor Name:

First

Last

Primary Doctor Phone #

Medical Status *

A Description of the medical condition and the reference where you gather this information, e.g., Doctor / Hospital Report

What’s the name of the medicine the patient currently use, and what is it for? *

List all medicines name/brand the patient currently uses and, what is for?

Patient Status

Is patient alert?

Always
Sometimes
Never

Can patient direct a home care worker?

Yes
No

If No, who is responsible for directing home care workers?

Name *

First

Last

Relationship to Patient

Impairments

Sensory

Speech

None
Partial
Total

Sight

None
Partial
Total

Hearing

None
Partial
Total

Muscular/Motor

Hand / Arm

None
Partial
Total

Upper Extremities

None
Partial
Total

Lower Extremities

None
Partial
Total

Cardiovascular/Respiratory

Respiratory

None
Partial
Total

Cardiac

None
Partial
Total

Circulatory

None
Partial
Total

Describe impact on functional ability

Does the patient have history of tuberculosis?

Yes
No
Pulmonary
Extra Pulmonary

Did patient complete therapy?

Yes
No

Does patient currently have tuberculosis?

Yes
No
Pulmonary
Extra Pulmonary

Is patient currently on tuberculosis prophylaxis

Yes
No

Hx of TB prophylaxis

Yes
No

If on tuberculosis treatment, are there 3 negative AFB

Yes
No

Negative chest X-ray

Yes
No

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Mental Status

Oriented place and time

Never
Partial
Total

Anxiety

Never
Partial
Total

Agitated

Never
Partial
Total

Short term memory loss

Never
Partial
Total

Wanders

Never
Partial
Total

Depression

Never
Partial
Total

Impaired judgment

Never
Partial
Total

Danger to: Others (Aggressive) Self :

Never
Partial
Total

Articulates needs

Never
Partial
Total

Sleep disorder

Never
Partial
Total

Abusive to: Others / Self

Never
Partial
Total

Other Cognitive/Mental

Never
Partial
Total

Other Status Information

Patient Ability to Take/Administer Medication

Totally independent

Never
Sometimes
Always

Needs reminding

Never
Sometimes
Always

Non-compliant

Never
Sometimes
Always

Needs help preparing

Never
Sometimes
Always

Needs administration

Never
Sometimes
Always

Patient/care giver can be taught to administer

Yes
No

Please explain

If patient is not independent, what arrangements have been made to administer medications?

IV Infusion and Injections:

Patient requires home infusion via:

e.g., Central Line, Peripheral Line

Injections

e.g., injection name / Type, # of Times Per Week

Blood work (in the home)

# of Times Per Week

Elimination:

Continent

Bowel
Bladder
N/A

Occasionally Incontinent

Bowel
Bladder
N/A

Incontinent

Bowel
Bladder
N/A

Medical Treatment: (Check all that apply) Please list all medications:

Checkboxes

Decubitus care
Dressings – Simple
Dressings – Sterile
Enema
Catheter care
Monitor Vital Signs
Tube feeding
Tube irrigation
Suctioning
Oxygen administration
Blood tests
Ambulation exercise
Rehabilitative therapy
Physical Therapy
N/A

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Identification of Service Needs

Ambulate inside

Without Help
With Cane
With Walker
With Wheelchair
With Personal Assistance
Unable

Ambulate outside

Without Help
With Cane
With Walker
With Wheelchair
With Personal Assistance
Unable

Get up from seated position

Without Help
With Cane
With Walker
With Wheelchair
With Personal Assistance
Unable

Get up from bed

Without Help
With Cane
With Walker
With Wheelchair
With Personal Assistance
Unable

Transfer to Commode

Without Help
With Cane
With Walker
With Wheelchair
With Personal Assistance
Unable

Transfer to Wheelchair

Without Help
With Cane
With Walker
With Wheelchair
With Personal Assistance
Unable

Indicate Patient’s Personal Service Needs:

Grooming

Independent
Partial Assist
Total Assist

Dressing

Independent
Partial Assist
Total Assist

Washing

Independent
Partial Assist
Total Assist

Bathing

Independent
Partial Assist
Total Assist

Feeding

Independent
Partial Assist
Total Assist

Meal Preparation

Independent
Partial Assist
Total Assist

Reheat Meals

Independent
Partial Assist
Total Assist

Toileting/Bathroom

Independent
Partial Assist
Total Assist

Urinal or bedpan

Independent
Partial Assist
Total Assist

Commode

Independent
Partial Assist
Total Assist

Catheter

Independent
Partial Assist
Total Assist

Laundry

Independent
Partial Assist
Total Assist

Shopping

Independent
Partial Assist
Total Assist

Housecleaning

Independent
Partial Assist
Total Assist

Is the patient homebound?

Yes
No

*If the patient is not homebound, you must submit justification of home care separately.

Certification

The assessment is based on personal observation of the patient.

Yes
No

The assessment is based on information relayed to me by

Full Name, Relation to the Patient, Contact Number

Is any other agency/vendor providing services in the home to the patient?

Yes
No

If Yes, Agency Name

Type of service the other agency perform

Prepared By / Nurse' Name *

First

Last

Licence #

Date / Time

Signature

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