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Click ‘Get Form’ to open the DSS-3122 in the editor.
Begin by filling in the resident's NAME and ADDRESS at the top of the form. Ensure accuracy as this information is crucial for identification.
In the MEDICAL HISTORY section, provide details about the PRIMARY DIAGNOSIS, RECENT SURGERY, and any CHRONIC ILLNESS. This helps assess the individual's care needs.
Complete SECTION II by listing all MEDICATIONS NEEDED, including TYPE, FREQUENCY, and DOSAGE. This ensures proper medication management.
In SECTION III, answer questions regarding the individual's capabilities and conditions. Use 'yes' or 'no' to indicate their ability for self-administration and mobility status.
Finally, in SECTION IV, provide a detailed opinion on whether the individual requires support from an adult residential care setting. Include any necessary justifications.
Ensure that a physician signs and dates the form at the bottom before submission.

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