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WET FUNCTIONAL ASSESSMENT INTAKE SHEET Name: Age: Medical History Check the box if you have had any of the following: Diabetes Rheumatic fever Heart murmur High blood pressure Heart disease/pacemaker
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How to fill out functional assessment intake sheet
How to fill out a functional assessment intake sheet:
01
Start by providing personal information: Fill out your name, date of birth, contact information, and any other required personal details.
02
Answer demographic questions: Some intake sheets may include questions about your gender, ethnicity, or employment status. Answer these questions honestly and accurately.
03
Medical history: Provide information about any past or current medical conditions, surgeries, or hospitalizations. Include details about medications you are currently taking or any allergies you may have.
04
Functional limitations: Describe any physical or cognitive limitations you may have. This could include difficulties with mobility, activities of daily living, or mental health challenges.
05
Lifestyle and living environment: Share information about your current living situation, including whether you live alone or with others, the type of housing you have, and any support systems or services that are in place.
06
Activities and interests: Mention your hobbies, interests, and activities that you enjoy participating in. This information can help assess your quality of life and identify areas for improvement.
07
Goals and expectations: State your primary goals and what you hope to achieve through the functional assessment. It could be related to improving independence, managing chronic pain, or enhancing overall well-being.
08
Consent and signature: Read through the intake sheet carefully, ensuring you understand the information provided. If you agree to proceed and authorize the assessment, sign and date the sheet.
Who needs a functional assessment intake sheet?
Functional assessment intake sheets are typically used by healthcare professionals, social workers, or rehabilitation specialists to gather essential information about an individual's physical or cognitive abilities, limitations, and needs. These assessments can benefit various populations, including individuals with disabilities, older adults, individuals recovering from injuries, or anyone seeking support in improving their overall functionality and quality of life.
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What is functional assessment intake sheet?
The functional assessment intake sheet is a form used to gather information about an individual's abilities and needs in various areas of functioning, such as communication, mobility, and self-care.
Who is required to file functional assessment intake sheet?
Healthcare providers and social workers are typically responsible for filing the functional assessment intake sheet.
How to fill out functional assessment intake sheet?
To fill out the functional assessment intake sheet, you will need to provide detailed information about the individual's physical and cognitive abilities, as well as any support services or accommodations they may require.
What is the purpose of functional assessment intake sheet?
The purpose of the functional assessment intake sheet is to help healthcare professionals and caregivers create personalized care plans that meet the individual's specific needs.
What information must be reported on functional assessment intake sheet?
Information that must be reported on the functional assessment intake sheet includes medical history, daily living skills, communication abilities, and any specialized care needs.
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