* = Required Information
RN EVALUATION/BASELINE ASSESSMENT

Vitals

Glasses
Hearing Aid
Dentures
Cane
Wheelchair
Electric Cart/Scooter
Walker
Oxygen
Assistive Dressing Devices
Other

Yes No

Diagnosis

Vaccination Status

Yes No
Yes No

Sensory Losses and Communication Problems

Glaucoma
Cataracts
Macular Degeneration
ADLs
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
IADLs
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Independent
Needs minor assist
Needs super-vision/oversight
Needs assistance
Totally dependent
Rash
Itching
Cool
Pale
Moist
Flushed
Open Sores
Cellulitis
Other
Thyroid
Diabetes
Hyperglycemia
Hypoglycemia
Other
Stroke
Parkinson's
Headaches
Paralysis
TIA's
Dizziness
Seizures
Other
Heartburn
Constipation
Gastric reflux
Diarrhea
Nausea/Vomiting
Bowel Incontinence
Other
Heart Disease
High Blood Pressure
Pacemaker
Chest Pain
Edema
Heart Attack
Other
Urinary incontinence
Shortness of Breath
Pneumonia
Asthma
Cough
Emphysema
Bronchitis
Smoker/History of Smoking
Other
Fractures
Arthritis
Osteoporosis
Joint Replacement
Pain
Other
Alert
Oriented to
Forgetful
Sad/Depressed
Paranoid
Confused
Anxiety
Impaired Decision-making
Wanders
Memory Loss
Mental illness or cognitive impairment
Behavior issues (verbal or physical aggression)
Other

Other Issues or Problems:

Afraid of falling
Sleep patterns to
Cancer
Alcohol/controlled substance use
Has fallen in past year
Frequent Hospitalizations
Other
Over-the-Counter, Herbal and Prescribed Medications (if possible, do a “brown bag” assessment):
Add Medication

Evaluation/Baseline Assessment Completed by:

Security code