Individual / Member Name - (Last, First, Middle Initial)				Date of Birth
Individual's / Member's Medicaid ID Number	Start of Care Date	Sex Male Female	Lives Alone Yes No	Reason for Assessment Initial Change Ongoing
DAHS Facility Name		DAHS Nurse		DAHS Area Code and Telephone No.
DAHS Facility Address

A. Alteration in Nutrition/Metabolism

Choking, risk of aspiration	Low body weight	Inadequate fluid intake
Inadequate nutritional intake	Upset stomach/indigestion	Intake exceeds body's needs
Blood sugar fluctuations or abnormalities	Chewing Problem	Swallowing Problem
Use dentures	Some or all natural teeth lost - does not have/use or partial plates
Other/Specify:		N/A

B. Alteration in Elimination

Constipation	Diarrhea	Bladder incontinence program
Bladder incontinence	Bowel incontinence	Bowel incontinence program
other/Specify:		N/A

C. Alteration in Cardiac/Respiratory Status

Chest Pain	Cyanosis	Oxygen use	Blood presure fluctuations/abnormalities
Wheezing	Shortness of breath	Peripheral circulation issues (including edema)
Other/Specify:			N/A

D. Alteration in Skin

Pressure ulcer	Stasis ulcer	Lession other than pressure/status ulcer, including feet
Surgical Wound	Risk of skin breakdown	Swelling
Fragile skin	Rash
Skin desensitized to pain or pressure	Abrasions, bruises
Other/Specify:		N/A

E. Alteration/Deficit in Body Control

Unsteady gait	Amputation	Balanced - partial/total loss of ability to balance while standing
Quadriplegia	Hemiplegia/hemiparesis	Lack of hand dexterity (ie:problem using utensils)
Uses ambulation device	Paraplegia	Arm/Leg/trunk - Part or total loss of Voluntary movement
Other/Specify:		Contractures	N/A

F. Alteration in Neurological Status

Seizures	Tremors	Generalized weakness	Dizziness vertigo	Not oriented X3
Limitations in cognition		Other/Specify:		N/A

Individual/Member Name - (Last, First, Middle Initial)

Date of Birth

Individual's/Member's Medicaid ID Number

Form 3050
Page 2 / 6-2017-E

G. Altered Sensory Perceptual Awareness

Pain	Wears glasses or contacts	Hearing Deficit - minimally impaired
Vision deficit - minimally impaired		Hearing deficit - highly impaired
Vision deficit - highly impaired		Wears hearing aid
Other/Specify:		N/A

H. Communications Deficit

Difficulty making self understood, Limited to	Difficulty understanding	May miss intent or message
Making concrete request, Difficulty finding	Rarely/never understands	Only sometimes understands
Wording/finishing tgoughts		N/A
Other

I. Behavior Challenges

Wandering	Motor agitation	Failure to eat or take medication	Socially inappropiate or disruptive behaviors
Other			N/A

J. Vital Signs/Height/Weight/Blood sugar

Blood pressure	Pulse	Respiration	Temp. (optional)	Height	Weight	Blood sugar (optional)
Additional Comments:

SECTION III - Therapies and Treatments

Check therapies the individual/member is currently receiving from any source.
Speech - language pathology, audiology services	Physical Therapy	Psycology Therapy (licensed professional)
Ocupational Therapy	Respiratory Therapy	Radiation
Chemotherapy	Dialysis
Other

SECTION IV - Plan of Care at the DAHS Facility

Check the appropriate boxes if assistance with the task will be provided at the DAHS facility.
A. Transfer No Assistance Needed

Assistance Needed	Schedule/Frequency	Comments
Setup Required
One-Person Physical Assistance
Two-Person Physical Assistance

B. Ambulation No Assistance Needed
Individual/Member Uses the Following Aids: Cane Walker Wheelchair-Self Wheelchair-Assisted
Setup Required
One-Person Physical Assistance
Two-Person Physical Assistance

Individual/Member Name - (Last, First, Middle Initial)

Date of Birth

Individual's/Member's Medicaid ID Number

Form 3050
Page 3 / 6-2017-E

C. Eating No Assistance Needed
Individual/Member Uses the Following Aids: Feding Tube Syringe (Oral Feeding) Plate Guard,stabilized Built-Up Utensil, etc. Other:
Assistance Needed	Schedule/Frequency	Comments
Setup Required
One-Person Physical Assistance
Two-Person Physical Assistance
D. Toileting No Assistance Needed
Individual/Member Uses the Following Aids: External (condom) Catheter Indwelling Catheter Intermittent Catheter Pads, Diapers
Toileting Program: Yes No	Ostomy Enema, Irrigation
Assistance Needed	Schedule/Frequency	Comments
Setup Required
One-Person Physical Assistance
Two-Person Physical Assistance
E. Bathing No Assistance Needed
Individual/Member Uses the Following Aids: Shower Hair Transfer Bench Handheld Shower Wand Sponge Bath
Assistance Needed	Schedule/Frequency	Comments
Setup Required
One-Person Physical Assistance
Two-Person Physical Assistance
F. Dressing and Grooming No Assistance Needed
Individual/Member Uses the Following Aids: Shaving Hair Care Brushing Teeth Nail Care Dressing
Assistance Needed	Schedule/Frequency	Comments
Setup Required
One-Person Physical Assistance
Two-Person Physical Assistance
G. Assistance No Assistance Needed
Individual Needs Assistance with Self-administering Medication
Medications	Schedule/Frequency	Comments

Individual/Member Name - (Last, First, Middle Initial)

Date of Birth

Individual's/Member's Medicaid ID Number

Form 3050
Page 3.1 / 6-2017-E

Individual Needs Assistance with Self-administering Medication
Medications	Schedule/Frequency	Comments

Individual/Member Name - (Last, First, Middle Initial)

Date of Birth

Individual's/Member's Medicaid ID Number

Form 3050
Page 4 / 6-2017-E

Section V – Therapeutically Benefit
This individual/member will benefit therapeutically from DAHS by:

Additional Information/Notes:

Section VI – Participation in Assessment
Individual/Member Yes No	Family Yes No	Significant Other Yes No	Responsible Party Yes No
Comments:

		Date

		Date Assesment Completed

Printed Name		Area Code And Telephone Number