Appendix B

Appendix B: Resident Individual Assessment – AASC OnLine Date of Assessment: Personal Data Unit No: Resident Name: Perso...

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Appendix B: Resident Individual Assessment – AASC OnLine Date of Assessment: Personal Data Unit No: Resident Name: Personal Functioning Personal Development: Do you observe the resident displaying any of these behaviors? □ Active □ Wants company □ Has limited support □ Has been active □ Wants friendship □ Never leaves home □ Wants to be active □ Wants to volunteer □ Has experienced a loss □ Wants work Notes/Comments:

Behaviors Observed □ Friendly □ Feels hopeless □ Pleasant □ Complains of threats □ Responsive □ Withdrawn □ Monotone speech □ Hallucinates □ Difficulty in speech □ Afraid Socialization Hobbies/Talent (Past or Present): Activities/Groups (Past or Present): How does the Resident typically spend a day? Notes/Comments:

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□ Tearful □ Suspicious □ Angry □ Anxious

Emotional Status Does the resident state or imply any of these behaviors? □ Loneliness □ Sleep problems □ Suicidal behavior □ Worry/Anxiety □ Easily upset □ Sleeping pills □ Suicidal talk □ Medication abuse Is the emotional status typical of resident’s lifelong emotional pattern, or just recent? □ Lifelong □ Recent Currently or ever received professional help/counseling? □ Yes □ No Community Supports Does resident acknowledge for assistance? □ Yes □ No Family and Friends Support need and Involvement Client has family and/or friends □ Who call regularly □ Assist sometimes □ Visit regularly □ Assist, but stressed □ Assist with care □ Have no family Other Agency Involvement Agency: Frequency: Agency: Frequency: Agency: Frequency: Transportation Has Transportation? □ Yes □ No Needs Transportation? □ Yes □ No Has Driver's License? □ Yes □ No

□ Resident refuses help □ Does not need help □ Resident is satisfied Service Provided: Service Provided: Service Provided:

Transportation Adequately Meets Resident's Needs? □ Yes □ No Has Vehicle / Access To A Vehicle? □ Yes □ No

Notes

Notes/Comments:

Mental Functioning (Based on professional observation) Alertness/Orientation: □ Disoriented Time: □ Memory impaired Place: □ Wanders Person: □ Forgetful □ Confused □ Flight of ideas □ Delayed reaction Appearance: Clothing: Grooming: Alcohol/Drugs: Signs of poor judgment: Notes/Comments

□ Inappropriate □ Not clean □ Slurred speech □ Strangers in home

□ Appropriate □ Unshaven □ Staggers □ Gives away $

□ Not fully clothed □ Body-urine odor □ Alcohol smell □ Lets nobody in home

□ Multilayer □ Satisfactory □ Empty bottles □ Appropriate