LOUISIANA OFFICE OF ELDERLY AFFAIRS - Cajun AAA



LOUISIANA OFFICE OF ELDERLY AFFAIRS

Louisiana Independent Living Assessment (LILA)

Statewide Comprehensive Needs Assessment Form

|3.1 COVER SHEET |

|Assessment Re-Assessment |Client’s Initials __________ Client a Veteran? ○-Y ○-N |

|Date:___________ Date:__________ |Nutrition Score__________ |

| |ADL____IADLS_____ Client a Veteran dependent ○-Y ○-N |

|First Name |Middle Name |Last Name |Clients Suffix |Client’s Maiden Name |

| | | | | |

| | | | |Client’s AKA Name |

|Marital Status |Client’s Gender |Client’s Date of Birth |

|○-D=Divorced |○-Male | |

|○-L=Legally Separated |○-Female | |

|○-M=Married | | |

|○-S=Single | | |

|○-W=Widowed | | |

|(6) Client’s SS #. |Client’s ID #. |Information Release Authorization |Clients Age in Years. |Clients Home Phone. |

| | |○-Y=Yes | | |

|____-____-____ | |○-N=No | |(_ _ _)_ _ _-_ _ _ _ |

|Clients Residence Address |Clients Mailing Address: |

|Street /P.O. Box__________________________ |Street Address__________________________ |

|Town__________________________________ |Town_________________________________ |

|State________________ Zip Code________________ |State_____________________ Zip Code_______________ |

|NAPIS |

|Ethnicity |

|○-H=Hispanic or Latino |

|○N= Not Hispanic or Latino |

|○-U=Unknown |

| Monthly Household Income |Household Size |Monthly Individual Income |Email Address |

|Characteristics |

|Abuse/Neglected/Exploited |Employment Status |Medicare Eligible |NSIP Meals Eligible |

|○-Y=Yes |○-Declined to state |○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |

|○-N=No |○-Full Time | | |

| |○-None |Receiving Social Security |Eligibility Type |

|Cognitive Impairment |○-Part Time |○-Y=Yes ○-N=No |○-Age 60 or over |

|○- Mild |○-Retired | |○-Disabled in Elderly Housing |

|○-Moderate |○-Unemployed |State Resident |○-Disabled living with elderly person |

|○-None |○-Unknown |○-Y=Yes ○-N=No |○- Food Handler |

|○-Severe | | |○-Guest/Staff under sixty |

|○-Unknown |Female Head of Household |Tribal |○-I&R Client |

| |○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |○-Not Indicated |

|Disabled | | |○-Other |

|○-Y=Yes |Frail |Understand English | |

|○-N=No |○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |Veteran |

| | | |○-Y=Yes ○-N=No |

| |Homebound |US Citizen | |

| |○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |Veteran dependent |

| | | | |

| | | |○-Y=Yes ○-N=No |

|Language |Homebound Waiting Score |

|○-English | |

|○-French |Personal Care Waiting Score |

|○-German | |

|○-Spanish | |

|Assessment Document | |

|Emergency Contact: | |

|(Lines 1.a.b.c.d.)Primary Physician |Relative/Friend(other than Spouse/Partner not living in the household) to contact in case of Emergency. |

|Name:_______________________________ | |

|Address:______________________________ |Name:________________________________________ |

|Phone:_______________________________ |Address:______________________________________ |

| |Phone:________________________________________ |

| |Relationship:___________________________________ |

|Directions to Client’s Home: |

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|1.A Intake |

| (1)What is the Date of the Assessment? |(2)Type of Assessment ○-Initial assessment ○-Reassessment |

|________/________/_______ | |

|(5)Where was the | Describe where the | (6)Did someone |(7) Name of the person|(8) What is the helper’s |(9)What is the name of the person conducting this assessment? |

|client interviewed? |client was |help the client or |that helps the client?|relationship to the client? | |

|○-1=Home |interviewed. |answer question for| | | |

|○-2=Hospital | |the client? | | |(10)What is the name of the agency the assessor works |

|○-3=Nursing facility | |○-Y =Yes | | | |

|○-4=Other | |○-N =No | | |for? _____________________________________ |

| (11)Was communication/language assistance needed for this |(12)Specify the client’s primary language. |

|assessment? |○-1=English ○-2=Spanish ○-3=French ○-4=Italian ○-5=Russian |

|○-1=Yes ○-2= No |○-6=Other |

| |(13)What type of communication/language assistance was need for this assessment? |

| |_____________________________________________________________________ |

| | |

|1.B Legal Representative: |

|Does the client have a power of |What is name of the client’s |Work phone number of the client’s |Does the client have a DPOA (Dual Power of |Does the client have DPOA for finances? |

|attorney? ○-Y=Yes |power of attorney? |power of attorney. |Attorney) for Health Care? |○-Y=Yes |

|○-N=NO | | |○-Y=Yes |○-N=No |

| | | |○-N=No |What is the name of the client’s DPOA for finances? |

| | |Home phone number of the client’s |What is name of the client’s DPOA for health |____________________ |

| | |power of attorney. |Care? _________________ |Work phone number of the client’s DPOA for |

| | |__________________ |Work phone number of the client’s DPOA for |finances._________________ |

| | | |health care._________________ |Home phone number of the client’s DPOA for |

| | | |Home phone number of the client’s DPOA for |finances____________________ |

| | | |health care.____________________ | |

|Does the client have a representative payee? |Does the client have a legal guardian? |Does the client have a living will? |

|○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |

| | | |

|What is name of client’s representative payee?__________________________ |What is name of the client’s guardian? |Name of person hold second copy of DPOA/Living Will. |

| | | |

|Work phone number of client’s representative payee.__________________ | | |

| |Work phone number of client’s guardian.__________________ |Address person hold second copy of DPOA/Living Will |

|Home phone number of client’s representative payee.__________________ | | |

| |Home phone number of client’s guardian.__________________ |Telephone number of person holding second copy of DPOA/Living |

| | |Will |

| | | |

| | |If the client does not have a living will, was information |

| | |provide about advanced directives? ○-Y=Yes ○-N=No |

|1.C Assessment Information |

|(1)What is the client’s main problem or reason for referred (when not a standard choice)? |(2)Who was the client referred by? |

|__________________________________________________________ |○-A=Self ○-B=Family ○-C=Hospital ○-D=Agency |

| |○-E=Other ○-F=Unavailable |

|What is the name of the agency that referred the client? |Who referred the client? |

|(3)Select the client’s current marital status. |(4)Indicate the type of residence that the client currently resides in. |

|○-A=Single |○-A=House/Mobile Home |

|○-B=Married |○-B=Private apartment |

|○-C=Separated |○-C=Private apartment in senior housing |

|○-D=Widowed |○-D=Residential care home |

|○-E=Divorced |○-E=Nursing home |

|○-F=Unavailable |○-F=Unavailable |

| |○-Z=Other |

|(5)How long has the client lived in her/his current residence? |(6.a)If the client has moved within the past three years, for how many months did s/he live in |

|○-A=Less than 12 months |this or her own home? |

|○-B=1-3 years | |

|○-C=3 years or more | |

|(6.b)If the client has moved within the past three years, for how many months did s/he live in a |(6.c)If the client has moved within the past three years, for how many months did s/he live in |

|residential care home? |other type of home? |

| | |

| |Describe the ‘other’ type of home the client live in. |

| | |

|(6.d)If the client has moved within the past three years for how many months did s/he live in a nursing |(6.e)If the client has moved within the past three years, for how many months did s/he live in a |

|home? |hospital? |

|(7)Select the clients living arrangement. |What is the name of the client’s spouse/partner? |

|○-A=Lives Alone | |

|○-B=With spouse/partner | |

|○-C=Lives with spouse and child | |

|○-D=With child/children | |

|○-E=Information unavailable | |

|○-F=With others | |

|(8)Is the client currently employed? | |

|○-Y=Yes-full/part time not specified ○-N=No | |

|9.a) Is the client participating in any of the following services or program? |9.b) Does the client want to apply for any of the following services or program? |

|○-A=Attendant services program |○-A=Attendant services program |

|○-B=Medicaid waiver |○-B=Medicaid waiver |

|○-C=Homemaker program |○-C=Homemaker program |

|○-D=Home health aide |○-D=Home health aide |

|○-E=Nursing |○-E=Nursing |

|○-F=Speech therapy |○-F=Speech therapy |

|○-G=Occupational Therapy |○-G=Occupational Therapy |

|○-H=Physical therapy |○-H=Physical therapy |

|○-I=Home delivered meals |○-I=Home delivered meals |

|○-J=Emergency lifeline |○-J=Emergency lifeline |

|○-K=Senior companion |○-K=Senior companion |

|○-L=Weatherization |○-L=Weatherization |

|○-M=Congregate meals |○-M=Congregate meals |

|○-N=VCIL peer counseling |○-N=VCIL peer counseling |

|○-O=Adult day services |○-O=Adult day services |

|○-P=Job counseling/vocational rehabilitation |○-P=Job counseling/vocational rehabilitation |

|○-Q=Food stamps |○-Q=Food stamps |

|○-R=Fuel Assistance |○-R=Fuel Assistance |

|○-S=Telephone lifeline |○-S=Telephone lifeline |

|○-T=Medicaid |○-T=Medicaid |

|○-U=SSI |○-U=SSI |

|○-V=V-Script |○-V=V-Script |

|○-W=QMB/SLMB |○-W=QMB/SLMB |

|○-X=Essential person program |○-X=Essential person program |

|○-Y=ANFC |○-Y=ANFC |

|○-Z=VHAP |○-Z=VHAP |

|○-0=Other |○-0=Other |

|10.a)How many people are in the client’s household |Specify the client’s monthly income? |

|○-A= One person |What is the client’s monthly income? |

|○-B=Two people |○- $1,178 or less ○-$695 or less |

|○-C=Three people |○- $1,420 or less ○-$937 or less |

|○-D=Four or more people |○- $1,662 or less |

|11)Does the client have any children nearby? |12.b)Does the client have contact with friends often enough? |

|○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |

| | |

|12.a)Does the client have contact with family often enough? |13)Is their a friend or relative that could take care of the client for a few days? |

|○-Y=Yes ○-N=No |○-Y=Yes ○-N=No |

|14)When the client makes a decision about something, how does s/he do it? |15)How does the client rate his/her health? |

| | |

|○-A=Independently and alone |○-A=Excellent |

|○-B=Independently after talking to family/friends |○-B=Good |

|○-C=Follow advice of family/friends |○-C=Fair |

|○-D=Dependent |○-D=Poor |

|○-E=Information unavailable |○-E=Information unavailable |

|16)In the past year, how many times has the client stayed overnight in the hospital? ○-Y=Yes |17)Has the client ever stayed in a nursing home, residential care home, or other institution? |

|○-N=No |○-Y=Yes ○-N=No |

|18)Indicate which of the following conditions/diagnoses the client currently has. |19)Is the client limited in what s/he can do be cause of the stroke/ neurological condition? |

|○- A=Heart problems ○-B=Arthritis ○-C=Diabetes |? ○-Y=Yes ○-N=No |

|○-D=Cancer ○-E=Stroke/neurological problems | |

|○-F=Mental/emotional condition ○-G=Breathing disorders |20)How often does bad health, sickness, pain, or disability stop the client from doing things |

|○-H=Cataracts ○-I=Urinary problems |s/he would like to do? |

|○-J=Ankle/leg swelling ○-K=Cognitive impairment/dementia | |

|○-L=Other |○-A=Never ○-B=Sometimes ○-C=Often ○-D=Always |

|21)Has the client fallen in the past three months? |22)In a typical week, during the last 30 days, how often did the client go outside of their |

| |residence (no matter for how short period of time)? |

|○-Y=Yes ○-N=No |○-A= Two or more days a week |

| |○-B=One day a week or less |

|23)Does the client use a walker to get around? |25)What was the client’s response when asked, what year is it? |

|○-Y=Yes ○-N=No |○-A=Correct answer |

|24)Does the client use a wheelchair to get around? |○-B=Incorrect answer |

|○-Y=Yes ○-N=No | |

|26)What was the client’s response when asked “What month is it? |27)What was the client’s response when asked “Where are you now? |

|○-A=Correct answer |○-A=Correct answer |

|○-B=Incorrect answer |○-B=Incorrect answer |

|28.a)Does the client have problems with hearing that are not corrected with aids/devices? |Describe the aids/devices used by the client to correct hearing problems. |

| | |

|○-Y=Yes | |

|○-N=No |28.d)Are the client’s hearing aids/devices in working order? |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|28.b)Does the client have problems with vision that are not corrected with aids/devices? |Describe the aide/devices used by the client to correct vision problems. |

| | |

|○-Y=Yes | |

|○-N=No | |

|28.e)Are the client’s vision aids/devices in working order? |28.c)Does client have problems with speech that are correct with aids/devices? |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes |

| |○-N=No |

|Describe the aids/devices used by the client to correct speech problems. |28.f)Are the client’s speech aids/devices in working order? |

| | |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|29)In the past six months, has the client lost more than 10 pounds without trying? |30)Does the client often feel sad or blue? |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|31)How many prescription medications does the client take? | |

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|Activities of Daily Living | |

|33. a) Can the client get around inside his/her home without help? |Does the client have help getting around inside? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Comment on the client’s ability to get around inside the home. | |

|33. b) Can the client bath him/herself without help? |Does the client have help bathing? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives bathing enough? |Comment on the client’s ability to bath him/herself. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.c)Can the client dress him/herself with help? |Does the client have help dressing? |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|○-Y=Yes ○-N=No ○-D=Don’t know |Is the help the client receives dressing enough? |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|33.d)Can the client get in and out of bed/chairs without help? |Is the help the client receives getting in and out of bed/chairs enough? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

| | |

|Does the client have help getting in and out of bed/chairs? |Comment on the client’s ability to get in and out of bed/chairs. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.e)Can the client use the toilet without help? |Is the help the client receives using the toilet enough? |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

| |Comment on the client’s ability to use the toilet. |

|Does the client have help using the toilet? | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

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|33.f) Can the client eat without help? |Does the client have help eating? |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives help with eating enough? |Comment on the client’s ability to eat. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.g)Can the client groom him/herself without help? |Does the client have help grooming his/herself? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the clients receive grooming his/herself enough? |Comments on the client’s ability to groom his/herself. |

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|○-Y=Yes ○-N=No ○-D=Don’t know | |

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|33.h)Can the client manage money without help? |Does the client have help managing money? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives managing money enough? |Comment on the client’s ability to manage money. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.i)Can the client do laundry without help? |Does the client have help doing his/her laundry? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives doing laundry enough? |Comment on the client’s ability to do laundry. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.j)Can the client take care of shopping without help? |Does the client have help doing his/her shopping? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|33.k)Can the client take his/her medication without help? |Does the client have help taking his/her medication? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives taking medication enough? |Comment on the client’s ability to take his/her medication. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|33.l)Can the client prepare meals without help? |Does the client have help preparing his/her own meals? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

| | |

|Is the help the client receives preparing meals enough? |Comment on the client’s ability to perform heavy household chores. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.m)Can the client perform heavy home chores without help? |Does the client have help performing heavy home chores? |

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|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives performing chores enough? |Comment on the client’s ability to perform heavy household chores. |

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|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.n)Can the client do ordinary housework without help? |Does the client have help doing ordinary housework? |

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|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives doing housework enough? |Comment on the client’s ability to do ordinary housework. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.o)Cam the client take out the garbage without help? |Does the client have help taking out the garbage? |

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|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives taking out the garbage enough? |Comment on the client’s ability to take out the garbage. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|33.p)Can the client use transportation without help? |Does the client have help using transportation? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives using transportation enough? |Comment on the client’s ability to use transportation. |

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|○-Y=Yes ○-N=No ○-D=Don’t know | |

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|33.q)Can the client use the telephone without help? |Does the client have help using the telephone? |

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|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Is the help the client receives using the telephone enough? |Comment on the client’s ability to use the telephone. |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

|Has the client made any changes in lifelong eating habits because of health problems? |Does the client eat fewer than 2 meals per day? |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|Does the client eat fewer than five (5) servings (1/2 cup each) of fruits or vegetables every day? |Does the client eat fewer than two servings of dairy products (such as milk, yogurt, or cheese) every|

| |day? |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|Does the client have biting, chewing or swallowing problems that makes it difficult to eat? |Does the client sometimes not have enough money to buy food? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

| | |

|Does the client eat alone most of the time? |Does the client take 3 or more different prescribed or over the counter drugs per day? |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |○-Y=Yes ○-N=No ○-D=Don’t know |

|Without wanting to has the client lost or gained 10 pounds in the past 6 months? |Is the client not always physically able to shop, cook and or feed themselves (or to get someone to |

| |do it for them)? |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

| | |

| |Does the client have 3 or more drinks of beer, liquor or wine almost every day? |

| | |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|Do you have prescription drug insurance? |Donations the client has been advised that he/she has an opportunity to make voluntary and anonymous |

| |donations for any service they may receive. |

|○-Y=Yes ○-N=No ○-D=Don’t know | |

| |○-Y=Yes ○-N=No ○-D=Don’t know |

|The client formally authorized release of information. | |

|Attached copy of signed and dated authorization to this assessment. |Clients Signature:_________________________________ |

| | |

|○-Y=Yes ○-N=No ○-D=Don’t know |Date of Signature: _________/_________/_________ |

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|List all services the client will receive in the bottom of this form. | |

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MEDICATION REVIEW (Addendum to PAF4019)

A. MEDICATION USE: (Ask the client if you can see the medications so that you can verify frequency, dosage, etc. Include over the counter drugs like aspirin, laxatives, and vitamins. Some medicines may be refrigerated.)

1. Are you taking any medicines? If so, could you show them to me so we can list their names and dosage?

| | | |PRESCRIBING DOCTOR AND PHONE | |

|MEDICATION |PRIMARY DIAGNOSIS |DIRECTIONS/STRENGTH/DOSAGE | |MANUFACTURER AND COST |

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| | | | | |

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2. Do you have problems or difficulty remembering to take your medications? a. Yes b. No

(If necessary, prompt the client by asking if s/he is concerned about forgetting. What steps does s/he take to remember?)

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3. Please list your drug allergies: _________________________________________________________

4. Referral made: _______

DETERMINE YOUR NUTRITIONAL HEALTH (Addendum to PAF4019)

|(CIRCLE YOUR ANSWERS AND ADD UP YOUR SCORE |YES |NO |

|Has the client made any changes in lifelong eating habits because of health problems? |2 |0 |

|Does the client eat fewer than two (2) meals per day? |3 |0 |

|Does the client eat fewer than five (5) serving (1/2 cup each of fruits and vegetables |1 |0 |

|Does the client eat fewer than two (2) servings of dairy products (such as milk, yogurt, or cheese) everyday? |1 |0 |

|Does the client have biting, chewing, or swallowing problems that make it difficult to eat? |2 |0 |

|Does the client have enough money to buy food? |0 |4 |

|Does the client eat alone most of the time |1 |0 |

|Does the client takes three (3) or more different prescriptions or over the counter drugs per day? |1 |0 |

|Without warning to, has the client lost or gained ten (10) pounds in the past six (6) months |2 |0 |

|Is the client not always physically able to shop, cook and or feed themselves (or to get someone to do it for them)? |0 |2 |

|Does the client have three (3) or more drinks of beer, liquor, or wine almost every day? |2 |0 |

|TOTALS | | |

(Add Yes and No columns) for your total nutrition score COMBINED TOTALS: ____________

If it is:

0-2 GOOD! Recheck the Nutritional Score in 6 months.

5. You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyles. Your area

agency on aging, senior center, or council on aging can recheck your Nutritional Score in 3 months

6 or more You are at high nutritional risk. Bring a copy of this checklist the next time you see your doctor, dietitian, or other qualified health or social service professional. Talk with them about problems you may have. Ask for help to improve your nutritional health.

SECTION 4.0 GOEA SCORE SHEET

|Client Name: _________________________ ID # __________ Nutritional Score ____ |

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|DATE: _______________Services Requested: ________________________________ |

1. Is this person low income?

Yes – 1 No - 0

2. Is this person a minority?

Yes – 1 No - 0

3. Is this person living alone?

Yes – 1 No - 0

4. What is the person’s ADL count (Score 0-6)

Count one (1) impairment for each ADL that the person

answered “no” (they cannot perform without help) on the

assessment. The ADLs are measured on Section 1: Intake,

Question 33 – a, b, c, d, e, and f.

5. What is the person’s IADL count (Score 0-8)?

Count one (1) impairment for each IADL that the person

answered “no” (they cannot perform without help) on the

assessment. The IADLs are measured on Section 1: Intake,

Question 33 – h, I, j, k, l, m, and n.

6. Is the person residing in a rural area?

Yes – 1 No – 0

7. What age is the person?

Below 75 – 0 75 – 84 – 1 85+ - 2

8. What level of support is currently available to this person?

High – 0 Moderate – 1 Very little or none – 2

9. Is the person on a special diet? ____ [i]TOTAL

10. Is the person homebound? _____

[ii]Assessor override: Eligibility for Priority status to override Total Score (Check all that apply – at least one must apply to be eligible)

____ (1) Client is an older individual in greatest economic need

____ (1) Client is older individual in greatest social need

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[i] The highest score is 24. Persons with the highest score on the waiting list should be served first.

[ii] Assessor utilizing the overrides is required to maintain documentation on file.

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