INTAKE - ANNUAL - QUARTERLY STATUS/MEDICAL UPDATE	Date	02-05-11
Client	MILLIE MCKNIFE	Meeting Date with Client	02-07-11
Staff	Penelope Pine	Meeting Date with WSC	02-21-11
Months Covered	Qtr 3/AR	Nov 2010-Jan 2011	Qtr 1	Qtr 2	Qtr 4/IP
STATUS UPDATE: Briefly explain any areas of importance to the individual, that have impacted the individual, or affected goal progress during this time. Ask the client to state what he knows/understands about each area. Explain how the client is empowered to make informed decisions about things that affect him (health, safety, rights, etc). Provide examples and use quotes if explanation is in the client's own words.
Intake with a new client?	Yes	No	X	Date of intake, if Yes.
Changes Needed?

No
General Well-Being

Good
Incidents/Complaints/

Grievances	None
Strengths/Capabilities

States she is "happy in her new home"
Barriers/Challenges

increasing age
Hobbies/Interests/

Projects	memory book, cooking, magazines, radio, checkers
Achievements of Special Note	moved to new home, Christmas party
Major Life Changes

moved to new home with new roommate
Needs

None
Participation in Activities (List)	cooking, out to eat, movies, shopping, household tasks
Social Inclusion/Uses Environment	goes shopping, out to eat, on picnics, to the mall, wants to try going to the Sunshine Center

Safety Issues/Makes Informed Decisions	needs to learn new fire procedures for new home
Health Issues/Makes Informed Decisions	None
Diet/Nutrition

Good
Proper Administration of Medications	Ok
Adequate Medications (5 days)	Ok
Personal Hygiene/

Self-Care	Good
Health Appointments/ Follow-up Appointments	Good
Satisfactory Dental Health	Good
Choices/Decisions Worked On	Makes decisions for meal planning, daily routine; working on not getting upset when staff assist her with or remind her about chores
Dignity/Respect Issues

None
Experiences Security/ Continuity	Feels safe in new home
Expresses Rights/States Rights that are Important	Yes
Goal Progress

Continues to work on goals

MEDICAL UPDATE: List the individual's health providers, hospitalizations, recent and upcoming appointments, and medications.
Health Providers

Medical/Dental/Mental Health (name, specialty, phone)	Xxx, primary, 123-1234
Yyyy, gyn, 567-8910
Zzzz, gastro, 111-1111
Aaaa, dental, 222-2222
Bbb, ophth, 333-3333
Hospitalizations -(date, hospital, purpose)
None
Recent/Upcoming Appointments- medical, dental, mental health (date, health provider, purpose)
Recent Appointments	Upcoming/Follow-up Appointments
12-01, Xxx, establish with new pcp	04-08, Lab, fasting b/w
01-18, Aaa, dental cleaning	04-18, Xxx, primary care follow up
07-19, Aaa, dental cleaning
Medications (name, strength, form, dose, purpose)
Boniva, 150mg tab, 1x month, bone health
Aspirin, 81mg tab, 1x day, heart health
Calcium citrate, tab, 2-1x day, bone health
Multivitamin, tab, 1x day, general health
Omeprazole, 20 mg cap, 2-1x day, stomach acid
Zafirlukas, 20mg tab, 1-2x day, allergies
Diovan, 80mg tab, 1x day, blood pressure
Docusate Sodium, 100mg cap, 1-2x day, regularity
Crestor, 10mg tab, 1x day, cholesterol
Atenolol, 100mg tab, 1x day, blood pressure
Fiber Capsules, 2-3 1x day, fiber
Amoxicillin, 500mg cap, 4-1hr before dental
Oxybutynin, 5mg tab, 1-2x day, bladder control
Individual	Signature	Date
Client
Guardian
Staff
WSC