GOLDEN ROSE ASSISTED LIVING

STATE OF GEORGIA

PERSONAL CARE HOME PHYSICIAN REPORT

Name DOB Height
Address Weight
City State Zip Telephone
1. Current Diagnosis
2. Physical Limitations
3. Mental Health Limitations
4. Treatment/Therapies (Describe medical services or nursing care treatment needed)
5. Support Services Needed
Medications/Instructions: List all medication; include route, dossage, and mode of administration.
Note: PRN for B or C must include instructions. Mode of Administration: A = Self administered;
B = Needs supervision to self administer, C = Needs administration by licensed professional
------ABC ------ABC
------ABC ------ABC
------ABC ------ABC
Diet Instruction: ____ Regular ____ No added table salt ____ No Conc. Sweets
____ Other ______

GOLDEN ROSE ASSISTED LIVING

PHYSICIAN’S REPORT

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Status of the following:
AMBULATING BATHING DRESSING EATING
___ Independent ___ Independent ___ Independent ___ Independent
___ Needs Supervision ___ Needs Supervision ___ Needs Supervision ___ Needs Supervision
___ Needs Assistance ___ Needs Assistance ___ Needs Assistance ___ Needs Assistance
___ Need total help ___ Need total help ___ Need total help ___ Need total help ___ Bedridden
GROOMING SKIN INTEGRITY TOILETING TRANSFERRING
___ Independent ___ Independent ___ Independent ___ Independent
___ Needs Supervision ___ Needs Supervision ___ Needs Supervision ___ Needs Supervision
___ Needs Assistance ___ Needs Assistance ___ Hygiene Assistance ___ Needs Assistance
___ Needs Total Help ___ Stage Three ___ Adult Brief s ___ Needs Total Help
___ Stage Four ___ CatheterCare/Assist
*enter location below ___ Ostomy ______
RESTRAINTS
___ Resquires no restraints
___ Requires chemical restraints TYPE: ______
___ Require physical restraints TYPE: ______
ALLERGIES:

GOLDEN ROSE ASSISTED LIVING

PHYSICIAN’S REPORT

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CHECK ALL THAT APPLY
___ Yes ___ No The individual has received screening for TB on _____/ _____/ _____ and has no apparent signs and symtoms of
infectious disease which is likely to be transmitted to other residents or staff ? Reading: ____________
___ Yes ___ No The individual’s behavior doesnot pose a dangerto self or othersthat is not controllable by medication?
___ Yes ___ No The individual needs assistance from staff during the night? If yes, please describe: ______
___ Yes ___ No The individual does not require 24 hour nursing supervision?
___ Yes ___ No Based on the type of care the staff of Personal Care Home may legally provide, the individual’s needs can be met in a Personal Care Home for Adults that is not a Medical Facility?
COMMENTS:
Typed Name of Examiner: Georgia License #:
Address of Examiner

Telephone Number: Date:
PLEASE RETURN COMPLETED FORM TO:
GOLDEN ROSE ASSISTED LIVING
A Charming New Alternative to a Nursing Home
P. O Box 670716, Marietta, Ga. 30066
Phone Number: (770) 971-6262 or (770) 429-8899
Fax Number: (678) 594-0969
ESTHER WOGHIREN
LPN/DNS