GOLDEN ROSE ASSISTED LIVING by HC1209180078

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									       THE WILLOWS ASSISTED LIVING
                               STATE OF GEORGIA
                     PERSONAL CARE HOME PHYSICIAN REPORT

Name                                                   DOB                   Height
Address                                                                      Weight
City                                           State                 Zip
Telephone
1. Current Diagnosis
2. Physical Limitations
3. Mental Health Limitations
4. Treatment/Therapies (Describe medical services or nursing care treatment needed)


5. Support Services Needed
Medications/Instructions: List all medication; include route, dossage, and mode of
administration.
Note: PRN for B or C must include instructions. Mode of Administration: A = Self
administered;
B = Needs supervision to self administer, C = Needs administration by licensed professional

            ---------------------------------- ABC           -------------------------------- ABC
            ---------------------------------- ABC           -------------------------------- ABC
            ---------------------------------- ABC           -------------------------------- ABC
Diet Instruction:      ____ Regular    ____ No added table salt ____ No Conc. Sweets
                      ____ Other ________________________________________________
      THE WILLOWS ASSISTED LIVING
                                     PHYSICIAN’S REPORT
                                                                                               PAGE 2
Status of the following:

AMBULATING                 BATHING                 DRESSING                EATING
___ Independent            ___ Independent         ___ Independent         ___ Independent
___ Needs Supervision      ___ Needs Supervision   ___ Needs Supervision    ___ Needs Supervision
___ Needs Assistance       ___ Needs Assistance    ___ Needs Assistance     ___ Needs Assistance
___ Need total help        ___ Need total help     ___ Need total help      ___ Need total help
  ___ Bedridden

GROOMING                   SKIN INTEGRITY        TOILETING               TRANSFERRING
___ Independent            ___ Independent       ___ Independent          ___ Independent
___ Needs Supervision      ___ Needs Supervision ___ Needs Supervision ___ Needs Supervision
___ Needs Assistance       ___ Needs Assistance  ___ Hygiene Assistance ___ Needs Assistance
___ Needs Total Help       ___ Stage Three       ___ Adult Brief s        ___ Needs Total Help
                           ___ Stage Four        ___ CatheterCare/Assist
                           *enter location below  ___ Ostomy _____________________

RESTRAINTS
 ___ Resquires no restraints
___ Requires chemical restraints        TYPE: ___________________________________________
 ___ Require physical restraints        TYPE: ___________________________________________


ALLERGIES:
       THE WILLOWS ASSISTED LIVING
                                      PHYSICIAN’S REPORT
                                                                                                       PAGE 3
CHECK ALL THAT APPLY
___ Yes       ___ No The individual has received screening for TB on _____/ _____/ _____ and has
no apparent signs and symtoms of

infectious disease which is likely to be transmitted to other residents or staff ? Reading:
_______________________________________

___ Yes       ___ No     The individual’s behavior does not pose a danger to self or others that is not
controllable by medication?

___ Yes    ___ No   The individual needs assistance from staff during the night? If yes, please
describe:
____________________________________________________________________________
____________________________________________________________________________
___ Yes       ___ No      The individual does not require 24 hour nursing supervision?

___ Yes        ___ No     Based on the type of care the staff of Personal Care Home may legally provide,
the individual’s needs can be met in a                                 Personal Care Home for Adults
that is not a Medical Facility?

COMMENTS:


Typed Name of Examiner:
Georgia License #:

Address of Examiner


Telephone Number:                                                                              Date:

PLEASE RETURN COMPLETED FORM TO:
                      THE WILLOWS ASSISTED LIVING
                    A Charming New Alternative to a Nursing Home
                       P. O Box 670716, Marietta, Ga. 30066
                 Phone Number: (706) 210-3611 OR (678) 313-4673
                           Fax Number: (706) 210-0308

                                          ESTHER WOGHIREN
                                              LPN/DNS

								
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