Free Form 02AG003E (AG-2-A, PART II) - Oklahoma


File Size: 75.5 kB
Pages: 2
File Format: PDF
State: Oklahoma
Category: Court Forms - State
Author: Planning
Word Count: 640 Words, 3,849 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.okdhs.org/NR/rdonlyres/05C0A9FD-DFBE-468E-BCBE-3D12A1E158C6/0/02AG003E.pdf

Download Form 02AG003E (AG-2-A, PART II) ( 75.5 kB)


Preview Form 02AG003E (AG-2-A, PART II)
*02AG003E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES OLDER AMERICAN ACT ASSESSMENT
PART II. IN-HOME SERVICES: To be completed with Form AG-2-A, Part I for the following services: Home-delivered meals, homemaker, personal care, chore, and Area Agency on Aging (AAA) case management. Consumer's full name as shown on Form AG-2-A, Part I:
Last First Middle Date

Is the assistance of another person required for the consumer to leave home (homebound)? ACTIVITIES OF DAILY LIVING (ADL) Would you say that you need assistance with: Dressing: Includes getting out clothes, putting them on, fastening them, and putting on shoes. Bathing: Includes running the water, taking the bath or shower, and washing all parts of the body, including hair. Eating: Includes eating, drinking from a cup, and cutting food. Transferring: Includes getting in and out of a bed or chair. Toileting: How well can you manage using the toilet? Using the toilet independently includes adjusting clothing, getting to and on/off the toilet, and cleaning self if accidents occur. If person manages alone, count as no assistance. If reminders are needed to use the toilet count as some assistance/supervision. Walking. Includes the ability to move around inside the home, walking, and stairs.
No assistance Some assistance or supervision

Yes

No

*1Q9A2*
Can't do at all

*1Q9A1*
Comments

0

2

3

*5Q3A1*
0

*5Q3A2*
2

*5Q3A3*
3

*5Q4A1*
0

*5Q4A2*
2

*5Q4A3*
3

*5Q5A1*
0

*5Q5A2*
2

*5Q5A3*
3

*5Q6A1*

*5Q6A2*

*5Q6A3*

0

2

3

*5Q7A1*

*5Q7A2*

*5Q7A3*

0

2

3

*5Q9A1*

*5Q9A2*

*5Q9A3*

ADL total score: Add the numbers circled from Some assistance/supervision and Can't do it at all. ADL total score ADL impairment count: Count one impairment each time the consumer needs some assistance/supervisor or can't do it at all. ADL impairment count
OKDHS revised 8-13-2003 02AG003E (AG-2-A, PART II)

02AG003E (AG-2-A, PART II) INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) Would you say that you need assistance with: Transportation ability. Includes using local transportation or driving to places beyond walking distances. Preparing meals. Includes preparing meals for yourself including sandwiches, cooked meals, and TV dinners. Light housekeeping. Includes dusting, vacuuming, sweeping, etc., but does not include laundry. Shopping. Includes shopping for food and other things you need. Medication management. Includes taking your own medications, and keeping track of when and how much of each to take. Managing money. Includes handling your own money, keeping track of bills, and handling cash. Using telephone. Includes answering the telephone and making a telephone call. Heavy housekeeping. Includes heavy housekeeping, yard work, and doing your own laundry.
No assistance

OLDER AMERICAN ACT ASSESSMENT

Some assistance or supervision

Can't do at all

Comments

0

2

3

*5Q10A1* *5Q10A2* *5Q10A3*
0 2 3

*5Q11A1* *5Q11A2* *5Q11A3*
0 2 3

*5Q12A1* *5Q12A2* *5Q12A3*
0 2 3

*5Q13A1* *5Q13A2* *5Q13A3*
0 2 3

*5Q14A1* *5Q14A2* *5Q14A3*
0 2 3

*5Q15A1* *5Q15A2* *5Q15A3*
0 2 3

*5Q16A1* *5Q16A2* *5Q16A3*
0 2 3

*5Q17A1* *5Q17A2* *5Q17A3*

IADL total score IADL impairment count
Scoring matrix. Does consumer live alone? (Form AG-2-A, Part I) Does consumer require the assistance of another person to leave home? (Form AG-2-A, Part II) Yes (1 pt.) Yes (1 pt.)

Activities of daily living and instrumental activities of daily living.
ADL enter count: IADL enter count: Consumer support. Does the consumer receive any assistance/services, formal or informal, in ADL or IADL areas? Total score: Risk category. Check one. Low (0 - 3) Moderate (4 - 13) High (14+) Enter score Enter score No assistance (3 pts.) Assistance is available, but inadequate, fragile, etc. (2 pts.) Assistance is adequate overall (0 pts.)

Screener's signature:
2

Date:
OKDHS revised 8-13-2003