Health Assessment - Ontario Health atHome (Fixing Long-Term Care Act, 2021) — Form 4768-69E Completed Form Examples and Samples
Explore a detailed example of a completed Health Assessment - Ontario Health atHome (Fixing Long-Term Care Act, 2021) — Form 4768-69E. This sample provides a clear guide and template for filling out the form correctly, including patient details, health history, and care recommendations.
Health Assessment - Ontario Health atHome Form 4768-69E Example
How this form was filled:
This example shows a completed Health Assessment form for an elderly individual, Eleanor Vance, who requires at-home care due to mobility issues and chronic conditions. The form details her personal information, health history, functional status, and the assessor's recommendation for personal support and nursing services to enable her to live safely at home.
Information used to fill out the document:
- Patient Name: Eleanor J. Vance
- Health Card Number: 1234-567-890-YV
- Date of Birth: 1946-05-21
- Address: 456 Maple Avenue, Toronto, ON, M4B 1B4
- Assessment Date: 2026-02-10
- Assessor Name: Sarah Chen, RN
- Assessor Designation: Registered Nurse
- Primary Diagnoses: Osteoarthritis, Hypertension, Type 2 Diabetes
- Functional Status: Requires assistance with bathing and dressing. Uses a walker for mobility.
- Cognitive Status: Alert and oriented. No cognitive impairment noted.
- Recommended Care: Personal Support Worker (PSW) 2 hours/day for personal care and meal prep. Registered Nurse (RN) visit 1x/week for medication management and health monitoring.
- Emergency Contact: David Vance (Son)
- Goal of Care: To remain living safely and independently in own home with support.
What this filled form sample shows:
- Accurate completion of Patient Information and Health History sections.
- Detailed assessment of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
- Clear documentation of medical diagnoses and current functional limitations.
- Specific care plan with recommended services, frequency, and duration.
- Properly signed and dated by a qualified health care professional (Assessor).
Form specifications and details:
| Form Name: | Health Assessment - Ontario Health atHome (Fixing Long-Term Care Act, 2021) |
| Form Number: | 4768-69E |
| Jurisdiction: | Ontario, Canada |
| Use Case: | Assessment for an elderly individual requiring long-term care services at home due to chronic conditions and mobility limitations. |
Created: February 13, 2026 01:40 AM
