Free Nursing Home Health Assessment Form

Please fill out this form to assess the resident's current health status and care needs.
Resident Information
Name
Date of Birth
Room Number
Primary Health Concerns
Please list any primary health concerns or conditions
Current Medications
Name | Dosage | Frequency |
|---|---|---|
Mobility and Physical Abilities
Independent
Requires Assistance
Non-Ambulatory
Additional Notes
Dietary Needs and Restrictions
Regular Diet
Soft Diet
Low-Sodium
Diabetic
Cognitive Function
Alert and Oriented
Mild Cognitive Impairment
Moderate Cognitive Impairment
Severe Cognitive Impairment
Additional Notes
Allergies
Please list any known allergies
Emergency Contact Information
Name
Relationship
Phone number
Signature
Name:
Date:
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Support resident care with the Nursing Home Health Assessment Form Template from Template.net. This customizable and editable form enables comprehensive documentation of resident health assessments, ensuring essential health details are consistently recorded. Use the Ai Editor Tool to adjust the form to specific care needs, providing a valuable tool for effective resident health management. Grab yours!