CareKit Forms

Last Revised: 3-20-24

Assessment Tool

Assessment Info
Organization Type
Name
Sex
Primary Physician
Admitted From

Did the client live alone prior to admission?

Lived Alone Prior to Admission
Legal Representation
Legal Representation
Representative Contact Information
Interaction with Family and Friends
Visited by Family / Friends
Talks by Phone with Family / Friends
Other Programs
ER Visits
Social Life
Memory / Recall

Check all that the client was able to recall during the last 7 days

Memory and Use of Information
Memory and Use of Information
Cognitive Skills for Daily Decision-Making
Cognitive Skills for Daily Decision-Making

Judgment and ability to make decisions regarding daily life tasks

Behavioral Symptoms (Select if present during the last 30 days)
Wandering
Behavioral Demands on Others
Agitated, Disruptive and/or Aggressive
Awareness of Needs / Judgment
Mental Health History
Does the client have a mental health diagnosis?
Depression Screening

Over the last two weeks, how often have you been bothered by any of the following.

Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Thoughts of hurting yourself or that you would be better off dead
Anxiety Screening

Over the last two weeks, how often have you been bothered by any of the following.

Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Trauma and Stressors
Trauma Support / Stressors
Cognitive Functioning
Do you sometimes feel worried or confused?
Substance Use

In the past 6 months, how often have you used the following:

Alcohol Use
Nicotine / Tobacco
Marijuana
Other Substances

For example: cocaine, meth, heroin, hallucinogens, inhalants, designer drugs

Prescription Drug Misuse

Using prescription drugs not as prescribed:

Substance Use History
Have you ever felt you ought to cut down on your drinking or drug use?
Are you currently or have you received treatment for substance use?
Housing
Housing Condition
Worried About Losing Housing
Housing Support Available
Safety
Can the client live safely in their current environment?
Do you feel safe where you live?
Has anyone entered your home without permission?
Are you afraid of anyone?
Is anyone using your money without permission?
Food Security

In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there was not enough money for food?

Cut or Skipped Meals Due to Lack of Money
Were you often hungry but did not eat?
Did you eat less than you felt you should?
Social Connections
Who does the client live with?
How often do they see or talk to people they are close to?
Family Member / Individual Supports
Is the client caring for anyone?
Does the client have help when needed?
Is there a caregiver assisting?
Is the caregiver having difficulty?
Does client have an IHSS worker?
Benefits and Other Services
Run out of money before end of month?
Current Work Situation
Unpredictable Work Schedule?
Any concerns about job?
Legal Involvement
Time Spent in Jail / Prison
Current or Past Gang Involvement
Advance Care Planning
Advance Directive on File
Authorized Representative
Client Wants Information About Advance Directives
ADL Self-Performance (Last 7 Days)
Bed Mobility

Client's performance during last 7 days with or without assistive device

Transfer
Locomotion in Residence
Dressing
Eating
Toilet Use
Personal Hygiene
Bathing
Assistive Devices / Environmental Modifications
Cane
Walker
Wheelchair
Assistive Dressing Devices
Assistive Feeding Devices
Shower Chair
Grab Bar for Toilet
Grab Bar for Tub / Shower
Other Transfer Aids
Modification of Tub / Shower
Handheld Shower Head
Raised Toilet Seat
Other Aids
Ambulatory Status
Is the client ambulatory?

Ambulatory = able to leave a building without the assistance of a person or a mechanical device (except a cane)

ADL and IADL Functional Rehabilitation Potential
Continence (Last 14 Days)
Bladder
Bowel
Hearing
Hearing

Ability to hear with aid if used

Communication Devices
Modes of Expression
Making Self Understood
Ability to Understand Others
Vision
Vision

Ability to see in adequate light and with glasses if used

Active Diagnosis
Endocrine / Metabolic / Nutrition
Heart / Circulation
Musculoskeletal
Neurological
Psychiatric / Mood
Pulmonary
Sensory
Other
Infections
Medications
Capable of Taking Medications Independently
Knows What Medications Are For
Knows How to Take Medications
Knows How Often to Take Medications
Capable of Communicating Medication Effects
Receives Injections
Medication Allergies
Oral / Nutritional Status
Recent Weight Loss
Recent Weight Gain
Food Allergies
Skin Condition
Skin Treatments
Other Treatments / Procedures
Oxygen
Blood Sugar Monitoring
Catheter
IPPB / Respiratory Treatment
Colostomy
Ileostomy
Tracheostomy
Gastrostomy / Feeding Tube
Enemas
Other Procedure
Rehabilitation and Restorative Care
Training / Skill Practice

Only necessary to complete if requesting eligibility for Tier 5 Services

Participation in Assessment
ALWPP Eligibility
Tier Level
SNF Residency
Signatures
Facility Information
Current Medications
Mood and Behavior Patterns — Verbal Expressions of Distress
Negative Statements - Frequency
Negative Statements - Persistence
Repetitive Questions - Frequency
Repetitive Questions - Persistence
Repetitive Verbalizations - Frequency
Repetitive Verbalizations - Persistence
Persistent Anger - Frequency
Persistent Anger - Persistence
Self-Deprecation - Frequency
Self-Deprecation - Persistence
Unrealistic Fears - Frequency
Unrealistic Fears - Persistence
Feeling Something Terrible Will Happen - Frequency
Feeling Something Terrible Will Happen - Persistence
Repetitive Health Complaints - Frequency
Repetitive Health Complaints - Persistence
Anxious Complaints - Frequency
Anxious Complaints - Persistence
Mood and Behavior Patterns — Sleep-Cycle Issues
Unpleasant Morning Mood - Frequency
Unpleasant Morning Mood - Persistence
Insomnia / Change in Sleep - Frequency
Insomnia / Change in Sleep - Persistence
Mood and Behavior Patterns — Sad / Apathetic / Anxious Appearance
Sad / Pained Facial Expression - Frequency
Sad / Pained Facial Expression - Persistence
Crying / Tearfulness - Frequency
Crying / Tearfulness - Persistence
Repetitive Physical Movements - Frequency
Repetitive Physical Movements - Persistence
Mood and Behavior Patterns — Loss of Interest
Reduced Social Interaction - Frequency
Reduced Social Interaction - Persistence
Withdrawal from Activities - Frequency
Withdrawal from Activities - Persistence
Inpatient Hospital Stays (Last 12 Months)
Alcohol / Drug Treatment Hospitalization
Alzheimer's / Dementia Hospitalization
Psychiatric Hospitalization
IADL Self-Performance (Last 30 Days)
Heavy Housework
Shopping
Transportation
Managing Finances
Handling Cash
Meal Preparation
Telephone Use
Light Housework
Laundry
Can Client Stay Alone?
Respite Care Needed?