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Assessment Profile
Purpose:
Used to assess the most appropriate services that may meet the needs of the member. Please answer all questions.
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* Indicates required question
What is your First and Last Name?
*
Your answer
Please provide your preferred contact information:
*
Your answer
Does the member have skilled nursing needs?
*
Yes
No
Other:
Required
The member needs support with toileting?
*
Yes
No
Other:
Required
The member needs support with bathing
?
*
Yes
No
Other:
Required
The member needs support from 1 or 2 people for lifting/transferring
?
*
Yes
No
Other:
Required
The member needs support from the use of medical equipment for lifting/transferring
?
*
Yes
No
Other:
Required
The member needs support with seizures
?
*
Never
Sometimes
Often
Other:
Required
The member needs support with specific dietary needs such as diabetes or a special diet
?
*
Never
Sometimes
Often
Other:
Required
The member needs support with wound care/skin integrity
?
*
Never
Often
Sometimes
Other:
Required
The member exhibits physical aggression
?
*
Never
Sometimes
Often
Other:
Required
The member exhibits property destruction
?
*
Never
Sometimes
Often
Other:
Required
The member exhibits self-harming behaviors
?
*
Never
Sometimes
Often
Other:
Required
The member was hospitalized for psychiatric support or had crisis team intervention in the past 12 months
?
*
Never
Sometimes
Often
Other:
Required
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