interact positively with others (e.g. staff, family, residents)? Q7b: Can s/he 0 1 2 3 4 No 0 enjoy activities Yes 1 appropriate for his/her level of interests and abilities? Q8: Has 0 1 2 3 4 No 0 his/her family Yes 1 had as much information as wanted? Over the Past Week: Problems Problems Problems Problems Problems Cannot Intervention addressed/ mostly partly hardly not Assess offered or no problems addressed addressed addressed addressed provided? Q9: Have all 0 1 2 3 4 No 0 practical Yes 1 problems been addressed? (e.g. hearing aids, foot care, glasses, diet) Health Care Living Organ None Cannot Intervention Proxy Will Donation of Assess offered or Oral provided? Advance Directive Q10: check all 0 1 2 3 4 No 0 advance Yes 1 directives known to have been completed: What was the person’s last weight? weight lbs. What was the date s/he was last weighed?
interact positively with others (e.g. staff, family, residents)? Q7b: Can s/he enjoy activities appropriate for his/her level of interests and abilities? 0 1 2 3 4 No 0 Yes 1 Q8: Has his/her family had as much information as wanted? 0 1 2 3 4 No 0 Yes 1 Over the Past Week: Problems addressed/ no problems Problems mostly addressed Problems partly addressed Problems hardly addressed Problems not addressed Cannot Assess Intervention offered or provided? Q9: Have all practical problems been addressed? (e.g. hearing aids, foot care, glasses, diet) 0 1 2 3 4 No 0 Yes 1 Health Care Proxy Living Will Organ Donation of Oral Advance Directive None Cannot Assess Intervention offered or provided? Q10: check all advance directives known to have been completed: 0 1 2 3 4 No 0 Yes 1 What was the person’s last weight? weight lbs. What was the date s/he was last weighed?
IPOS-DEM-03162017-Electronic.docx