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CNA/HHA Assessment Form
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COMPLETED BY:
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NAME
TITLE
Patient Name
*
First
Date
MM slash DD slash YYYY
Total
Hours
Mins
Order Number
Date of Birth
MM slash DD slash YYYY
Time Arrived
Hours
:
Minutes
AM
PM
AM/PM
Time Departed
Hours
:
Minutes
AM
PM
AM/PM
PURPOSE OF VISIT
GENERAL INFORMATION
DIET
Regular
Diabetic
Low Sodium
Other
SKIN ASSESSMENT
Good Condition
Sores
Altered Color
Redness
Rash
Body Area Affected
Body Area Affected
VITAL SIGNS
Respiration
Temp.
Pulse
Weight
B/P Right Arm
B/P Left Arm
COGNITIVE STATUS
Alert
Oriented to Date & Time
Lethargic
Forgetful
Confused
ACTIVITIES OF DAILY LIVING (Check Appropriate Boxes):
COOKING/EATING
Preparing Meal
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Serving Meal
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Using Appliances
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Eating
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Using Utensils
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Fluid Intake
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Use Drinking Cups
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Cutting Food/Meat
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
BATHING/HYGIENE
Toilet Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Toileting/Wiping
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bath Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Shower Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bathing/Washing
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Brush/Comb Hair
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Shaving
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Clean Teeth
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Apply Makeup
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
MOBILITY
ROM (passive)
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
ROM (active)
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bed Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Move/Shift in Bed
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
DRESSING / GROOMING
UE Dressing
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
LE Dressing
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Don Shoes & Socks
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Tying Laces
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Patient Name
Date
MM slash DD slash YYYY
MEDICATION ASSISTANCE
Requires Medication Reminders?
Yes
No
Requires Medication Assistance?
Yes
No
Comments
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
Medication/Time
MEAL LOG
Breakfast
AM Snack
Lunch
PM Snack
Dinner
Evening Snack
COMPANION CARE
Assist with Morning Wake‐Up
Discuss News / Daily Events
Answer Telephone / Door
View Television / Movies
Write Letters & Correspondence
Gather Mail / Newspaper
Read Paper / Mail / Books
Meal Planning / Grocery Lists
Assist with Walking
Arrange Appointments
Care for House Plants
Participate in Crafts / Games
Visit Neighbors / Friends
Maintain Scrapbook / Mementos
Assist with Evening Tuck in
HOME AID
Prepare & Clean‐up Meals
Shop Groceries & Supplies
Organize Pantry / Closet
Clean Refrigerator
Dust Furniture
Make Beds
Change Linens
Laundry / Ironing / Fold Clothes
Vacuum / Sweep / Mop
Take Out Garbage
Escort to Appointments
Pick‐up Prescriptions
Drop‐off / Pick‐up Dry Cleaning
Assist with Pet Care
Escort to Beauty Salon / Barber
Time
Hours
:
Minutes
AM
PM
AM/PM
Time
Hours
:
Minutes
AM
PM
AM/PM
Other Notable Observations
Daily Narrative
Caregiver's Signature
Date/Time
Patient's Signature
Date/Time
For Display Only
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