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NEEDS ASSESSMENT:
Psycho-social status:
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Functional status:
Ambulation and Transfers
Transfers: independent _____ cane/walker _____ w/c _____
assist of 1 _____ assist of 2______
Physical status:
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ATTENDANCE:
Which days do you want your loved one to attend the center?
DIETARY: Does your loved one have any dietary restrictions? If so, please describe how to
assist.
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Food portion sizes: S M L Diabetic Low Salt Low Cal Cut up foods
CAREGIVER ROLE:
Role of caregiver in service plan:
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Participant/caregiver signature:____________________________________________________
Date:___________________________
Staff signature:_________________________________________________________________
Date:___________________________