Wellness Assessment Complete the assessment below Wellness Assessment Form Complete at each monthly home visit, and at any contact where a health, safety, self-neglect, or unit-condition concern is observed or reported. "*" indicates required fields 1. VISIT INFORMATIONProgram / Site*Pick a site locationClient Name*Pick a tenant or clientSub Residents Include Sub ResidentsApartment #Pick a roomDate of Assessment Staff Completing Assessment*Type of contact* Home visit Office visit Community visit Telephone Attempted — no contact 2. STATUS OF PRIOR CONCERNScarry forward from last assessmentConcerns identified at the previous contact are:* No prior concerns Resolved Ongoing — continuing to monitor Escalated Prior concern(s) and what has changed since last contact3. ASSESSMENTcheck all that applyNo concerns observed or reported NO CONCERNS OBSERVED OR REPORTED — if checked, skip to Section 5 Health and physical condition Decline in mobility or frequent falls Noticeable weight change Signs of illness or injury Fatigue or weakness Poor hygiene or grooming Memory or cognitive concerns Increased isolation or withdrawal Since last contact (client-reported) Hospitalization Emergency room visit Recent EMS call New or changed medication Missed medical appointments Difficulty with daily activities Taking medications Getting to appointments Obtaining or preparing food Personal care Accessing medical care Unit condition Excessive clutter or hoarding Unsanitary conditions Pests Food spoilage Fire or safety hazard Utility problem 4. NARRATIVErequired if any box in Section 3 is checkedDescribe what was observed or reported, and the client's response.*5. STATUS AND ACTIONBased on today's assessment, the client's wellness status is* Stable Monitor Follow-up needed Immediate intervention Action taken* No action required Follow-up visit scheduled Supervisor notified Medical referral Property Management notified Case conference requested Emergency intervention Follow-up Date Staff Signature*Your NameYour NameYour NameYour NameSupervisor review is required when the status is Follow-up needed or Immediate intervention. Your supervisor will sign from an emailed link.6. SIGNED COPYYour supervisor is emailed a link to review and sign when the status above is Follow-up needed or Immediate intervention. The signed PDF is emailed to you and your supervisor, and filed with Main Office.Staff Email* Supervisor Email*
