Personal Care Agency Functional Assessment Form 2026

1. Click ‘Get Form’ to open the Personal Care Agency Functional Assessment Form in our platform.
2. Begin by entering the Member Name and Assessment Date at the top of the form. This information is crucial for identifying the individual being assessed.
3. Fill in the Medicaid ID #, Date of Birth, and Diagnosis fields. Accurate details here ensure proper documentation and care planning.
4. Assess the functional status by selecting appropriate levels for ADL/Mobility/Cognitive functioning, Bowel and Bladder management, and Medication Management. Use the provided scale (1-4) to indicate the level of assistance needed.
5. In the 'Describe What Assistance is Needed' section, provide detailed descriptions for each personal care service required, such as bathing, dressing, and mobility assistance.
6. Indicate if the client is at risk of falling by selecting 'Yes' or 'No' under Mobility. This helps in planning safety measures.
7. Complete the Cognitive Functioning section by assessing communication abilities and understanding directions. Provide any special instructions as necessary.

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