Idaho Medical Power of Attorney Form by gtj14598


Idaho Medical Power of Attorney Form document sample

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									              IDAHO AREA AGENCY ON AGING INTAKE/REGISTRATION FORM                                                                           2
                           Area III Fax # (208) 322-3569                                           Date:              06/30/11 18:29        1
PROGRAM:         Home Delivered Meals      Homemaker       Respite          Other

Provider                                                             Site

Original                                                             Reporter Contact
Reporter                                                             Info.

Last Name                                                            First Name                                                  Initial

Nickname                                                             Phone Number
Residential                                                          City, State
Address                                                                  Zip
Mailing                                                              City, State
Address                                                                  Zip
Date of Birth                                          Gender                       # of people living in household      0

Do you live in a rural area?                                    Is your household monthly income below:
                                                       Has this person lost their primary
Is this person a caregiver?                                                                        Is this an Adult Protection
                                                       caregiver in the household?
Is this person a carereceiver?
         Race/Ethnic Origin                        Marital Status                   Does this person speak English?
                                                                                    Is this person Homebound?
                                                 EMERGENCY CONTACT INFORMATION
Name:                                                                Name:
Home                                    Mobile                       Home
                                                                                                                Mobile Phone:
Phone:                                  Phone:                       Phone:
Business                                                             Business
Phone:                                                               Phone:
Relationship:                                                        Relationship:

Was this person recently discharged from Hospital, Nursing Home or Rehab Facility?                                 Date of Discharge:


                                                                                    Primary Physician
Primary Physician
                                                                                    Phone #
Is there a medical condition which                     If "Yes"
needs immediate intervention?                          describe:
                                                         Administrative Use Only
Potential Services:                                                SAMS ADL                                  SAMS IADL
                                                                   High Nutritional Risk                NO

                                                                     Release of Information             NO

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                                                       FUNCTIONAL ABILITIES
ADL's                                                  Type of Needed Assistance            Assistance Available
Identify the client's ability to:
Eat Independently (feed self)                           None                                Enough
Get to and from toilet.                                 None                                Enough
Walk by self.                                           None                                Enough
Transfer from bed or wheelchair by self                 None                                Enough
Dress & undress by self.                                None                                Enough

Bathe/wash hair by self.                                None                               Enough

IADL's                                                 Type of Needed Assistance          Assistance Available
Identify the client's ability to:
Prepare meals.                                          None                               Enough
Transport or get transportation by self                 None                                Enough
Pay bills by self. (Manage Money)                       None                                Enough
Shop for food/personal items/run errands                None                                Enough
Do laundry by self.                                     None                               Enough
Clean House by self.                                    None                                Enough
Seek emergency help by self.                            None                                Enough
Administer own medications                              None                               Enough
Perform outside chores & maintenance                    None                               Enough
Use the telephone                                       None                                Enough
Client's need for supervison.                           None                                Enough

                                                       NUTRITIONAL HEALTH

Does the client eat fewer than 2 meals per day?                                                      No

Does the client eat few (less than 2) vegetables or fruits, or milk products per day?                No
Does the client have 3 or more drinks of beer, liquor or wine almost every day?                      No
Does the client have tooth or mouth problems that make it hard to eat?                               No
Does the client sometime not have enough money to buy food?                                          No
Does the client eat alone most of the time?                                                          No

Does the client take 3 or more different prescribed or over-the-counter drugs per day?               No
Without wanting to, has the client lost or gained 10 pounds in the past 6 months?                    No
Has illness or condition made the client change the kind and/or amount of food eaten?                No
Is the client not always physically able to shop, cook and/or feed themselves and has no help?       No
Is the client on a special diet or restricted foods?                                                 No
If "Yes" explain:

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                                                   CAREGIVER SECTION               Must be completed: NO

Name of Care
                                                                                        Is the caregiver paid?
How is the caregiver related to                                    Parent            Child
                                                Spouse                                                       Grandchild
Care Receiver?
                                                Other Describe

  List additional
  caregivers and

Does the care receiver need assistance with ADL's
                                                                                         24 Hour Care?
(eating, toileting, walking, transferring, dressing, bathing)?

Does the care receiver live with Alzheimer's disease or related disorders                    Is the care receiver a child
with neurological and organic brain dysfunction?                                             with severe disabilities?

Does this person have                Name:
Financial Power of
Attorney?                            Phone #:

Does this person have                Name:
a State appointed
Guardian?                            Phone #:

             HOME DELIVERED MEALS                    Start Date:                                  PRIORITY SCORE RECAP
                                        Anticipated End Date:
                                                                                      Lives Alone
                                                                                      Lives in Rural Area
                                                                                      Income Below Poverty
                                                                                      Race/Ethnic Origin Miniority              1
                                                                                      English Speaking
                                                          Frozen                      Adult Protection Referral
  # of meals approved per week
                                                           Meals                      ADL Total
                                                                                      IADL Total
                                                                                      Nutritional Health Total
Special Diet
                                                                                      Total Priority Score                      1

Units of service will only be reimbursed if the consumer meets eligibility criteria for the specified program(s).
Consent release: I do authorize              Yes    I do NOT authorize           No        the release of information to aging network.
I understand this information must be updated at least annually and will be release to the Southwest Area Agency on Aging and
providers associated with Southwest Area Agency on Aging for sole purposes of assisting me to receive services and benefits to
which I may be entitled.

Client or Authorized Representative Signature                                                   Date

Interviewer Signature                                                                           Date
AAA Reviewer Signature                                                                          Date


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Client Name:                                                              Referal to Case Management        Yes      No

Require minimal assistance with one or more ADLs or IADLs;
Require multiple services from health/social services providers;
Unable to obtain the required health/social services for themselves;
Lack available family or friends who can provide the needed assistance;


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