Resident Details

Full Name:

Date of Birth:

Gender:

Address:

Phone Number:

Emergency Contact:

Emergency Contact Number:

Relationship to Resident:

Healthcare Proxy (if applicable)

Healthcare Proxy Name:

Relationship to Resident:

Contact Number:

Medical History

Chronic Conditions:

Allergies:

Current Medications:

Functional Status

Mobility:

Activities of Daily Living (ADLs) Assistance Needed:

Cognitive Function:

Falls Risk

History of Falls:

• Yes

• No

Mobility Status:

• Low

• Moderate

• High

Assistive Devices in Use:

• Yes

• No

Environmental Hazards Identified:

• Yes

• No

Previous Falls Risk Assessment Scores (if available):

[0]

Pressure Ulcer Risk

Braden Scale Score:

[0]

Mobility:

• Impaired

• Limited

• Normal

Skin Condition:

• Healthy

• Compromised

Previous History of Pressure Ulcers:

• Yes

• No

Nutritional Risk

BMI (Body Mass Index):

[0]

Weight Change in Past Month:

[0]

Appetite:

• Good

• Fair

• Poor

Dietary Restrictions:

• Yes

• No

Infection Risk

Immunization Status:

• Up to Date

• Not Up to Date

History of Recent Infections:

• Yes

• No

Skin Integrity:

• Intact

• Compromised