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Have you had a physical in the last 2 years?
Height & Weight
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Weight (lbs)
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Health Issues
Issues Description
Medication List
Medications and Dates
How long have you needed care for?
Years *
Months *
Use this list as a reference when answering the section below.
Activities of Daily Living (ADL) - The Activities of Daily Living (ADL) refer to basic functional abilities that measure an individual’s ability for self-care and ability to live independently without substantial assistance from another individual.
The six activities of daily living include:
Bathing
Continence (bowel or bladder control)
Dressing
Eating
Transferring (moving into or out of a chair or bed)
Toileting
Have you had or currently have any issues in the following areas of health?
Select all that apply to you:
ALS (Lou Gehrig's disease) Alzheimer’s/ dementia Alzheimer's, dementia, senility, mild cognitive impairment (MCI), organic brain syndrome, memory loss or other cognitive impairment Anxiety Aneurysm Ataxia Cerebral palsy Cerebrovascular disease, including history of: CVA (stroke), TIA (mini stroke) in the past 5 years Down syndrome Epilepsy — no seizures in last 2 years Huntington Disease Huntington Disease has been diagnosed in an immediate family member Hydrocephalus — 6 months post-surgery Hydrocephalus — with or without shunt placement Multiple sclerosis (MS) Multiple sclerosis, including relapsing-remitting disease Organic brain syndrome Paralysis paraplegia/quadriplegia Paralysis: hemiplegia Paralysis, hemiplegia, paraplegia or quadriplegia (excluding Bell's palsy) Parkinson’s disease Seizure disorders or history of same with active seizures in the last 4 years Stroke/cerebrovascular accident (CVA) Stroke — over 6 months from event, single episode, no residuals, no coexisting CAD or diabetes Stroke — multiple, with residuals and/or coexisting CAD, diabetes Stroke within the past 12 months, multiple stroke history, or stroke with significant cardiac disease history Stroke in the past 5 years TIA — no residual, single episode TIA within the past 6 months or 2 or more TIAs
Select all that apply to you:
Bone marrow disorder, Hodgkin's disease, leukemia, or lymphoma Cancer, internal Cancer: Any history within 5 years Cancer other than breast, colon, prostate, lung, or nonmelanoma skin cancer within the past 3 years Cancer including only breast, colon, prostate, or lung cancer within the past 6 months Cancer of the blood, bone, brain, esophagus, head/neck, liver, lung, kidney, ovary, pancreas, stomach, recurrent cancers (any type excluding basal) or cancer that has spread to other organs or lymph nodes Leukemia Lymphoma Multiple myeloma Skin cancer — nonmelanoma (i.e., basal cell, squamous cell) Skin cancer — melanoma
Select all that apply to you:
Aortic/mitral insufficiency — mild, no symptoms, no surgery being considered Atrial fibrillation — stable, no coexisting heart, stroke or diabetes Cardiomyopathy — Active or with treatment in the last 5 years Cardiomyopathy within the past 3 years Cardiomyopathy — mild Cardiomyopathy of any severity Congestive heart failure: Active or treated in the last 3 years Coronary heart disease (e.g., heart attack, angioplasty, bypass) — favorable risk factors, asymptomatic, no coexisting diabetes or vascular disease Congestive heart failure (CHF) Defibrillator Heart valve replacement Hypertension — stable with treatment Pacemaker — 6 months post insertion, stable, no coexisting CAD/diabetes Peripheral vascular disease — no coexisting CAD or diabetes Ventricular tachycardia Heart attack, heart or carotid artery surgery within the past 6 months Implantable defibrillator
Select all that apply to you:
Alcoholism — active Alcoholism — recovered for 3 years Alcoholism — recovered for less than 5 years Bipolar disorder Bipolar disorder, mania, recurrent major depression, or schizophrenia Depression — severe, hospitalized within last 5 years Depression — moderate to severe Depression — mild/stable on treatment Drug addiction/illicit drug usage — recovered less than 5 years Drug addiction/illicit drug usage — within 10 years Drug abuse or dependency; controlled substance, illegal or prescription drugs Memory loss Forgetfulness, confusion or cognitive impairment Mental disorders, including: Bipolar disorder, schizophrenia, paranoia and psychosis Mental retardation Schizophrenia Steroid-dependent condition (six months or longer) Suicide attempt or suicidal ideation Tobacco usage — if in combination with diabetes, COPD, CAD, CVD or PVD Tobacco use in combination with heart, carotid, vascular or respiratory disease, diabetes, osteoporosis, stroke/TIA, sleep apnea, and/or clotting disorder Use of any narcotic drug or prescription pain medication currently or within the last 3 months (dental work narcotic pain prescription medications are excluded)
Select all that apply to you:
Activity of daily living deficit Activity of daily living deficit in any way in the past 24 months Any medical condition that has restricted your mobility or has impacted ADLs in any way Balance disorder/gait impairment Cane — quad or 3-prong Chronic pain — Tx non-narcotics Eating disorders — recovered less than 5 years Falls — 2 or more in last year Falls — Multiple or unexplained in the last 2 years Handicap parking sticker/plate History of falls due to gait disturbance or dizziness, or two or more falls in the last 36 months Imbalance or unsteady gait Imbalance, unsteady gait, or ataxia Narcotic pain killer — currently using Oxygen use Receiving disability payments Residing in an assisted living facility, including continued care retirement community or group home, or receiving home care assistance Surgery pending — will review after surgery and released from doctor’s care Using wheelchair or walker Use of cane or any variety, walker, or wheelchair currently or within the last 12 months Multiple DUIs Current probation or jail Felony within last 5 years Scuba diving greater than 130 feet Currently collecting any type of disability or worker’s compensation payments Diagnostic testing planned, scheduled or recommended that has not been completed Surgery planned, scheduled or recommended that has not been completed Surgery completed, not fully recovered and not yet released from physician care related to the surgery Use of a handicap permit due to physical limitations or medical conditions Currently collecting any type of disability payments excluding VA disability benefits and maternity leave
*If you use any of the medications listed above, please select 'yes'.
Yes No
*If you are prescribed any of the medications listed above, please select 'yes'.
Yes No
*If you have used or currently use and of the items listed above within the last 24 months, please select 'yes'.
Yes No
*If you currently reside or have resided in within the last 24 months or plan to utilize any of the services listed above, please select 'yes'.
Yes No
If Other, please list.
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