Health Assessment - Ontario Health atHome (Fixing Long-Term Care Act, 2021) — Form 4768-69E Instructions

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This form contains 204 fields organized into 58 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Additional Comments
Additional Comments Text
Provide any additional comments or information not covered elsewhere in the form.
Max length: 5000 characters
Additional Comments on Substance Use
Additional Comments Text
Provide any additional comments related to substance use, such as the history of substance use.
Max length: 5000 characters
Additional Details on Behaviours
Additional Behaviour Details Text
Provide additional details regarding the applicant's behaviours, including frequency of exhibited behaviours, triggers, and interventions.
Max length: 5000 characters
Additional Wound Information
Additional Wound Information Text
Provide any additional information related to wounds, such as history, location, stage of pressure injury/injuries, current wound care treatment, and specialty supplies required.
Max length: 5000 characters
Advance Care Planning Discussion
Applicant Checkbox
Check this box if the practitioner has discussed advanced care planning and/or end of life care with the applicant.
Applicant's Family Checkbox
Check this box if the practitioner has discussed advanced care planning and/or end of life care with the applicant's family.
Substitute Decision Maker Checkbox
Check this box if the practitioner has discussed advanced care planning and/or end of life care with the substitute decision maker.
Not known Checkbox
Check this box if it is not known with whom the practitioner has discussed advanced care planning and/or end of life care.
Other Checkbox
Check this box if the practitioner has discussed advanced care planning and/or end of life care with someone other than the applicant, their family, or a substitute decision maker.
Other Discussed Party Text
Please specify with whom the advanced care planning and/or end of life care was discussed, if not among the listed options.
Advance Care Planning Information
Advance Care Planning Information is Attached Checkbox
Check this box if information about advance care planning and/or end of life care planning or requirements is attached.
Advance Care Planning Details Text
Provide any known information regarding the applicant's advanced care planning, end-of-life care planning, or specific requirements.
Max length: 5000 characters
Alcohol Dependence
Alcohol Dependence Checkbox
Check this box if the individual has an alcohol dependence.
Allergies Information
Allergies Information is included Checkbox
Check this box if the applicant's allergies information is included in a cumulative patient profile attached to this form.
Has Known Severe Allergies Checkbox
Check this box if the applicant has known severe allergies (e.g., to drugs, food, latex, or stinging insects).
No Known Severe Allergies Checkbox
Check this box if the applicant does not have any known severe allergies.
Allergies Not Known Checkbox
Check this box if it is not known whether the applicant has any severe allergies.
Allergy Details Text
Provide specific details about the applicant's allergies, including severity, type of reaction, whether an EpiPen or auto-injector is required, and any treatment information.
Max length: 5000 characters
Applicant Information
Applicant's Last Name Text
Enter the applicant's last name.
Max length: 50 characters
Applicant's First Name Text
Enter the applicant's first name.
Max length: 30 characters
Health Card Number Text
Enter the applicant's health card number.
Max length: 12 characters
Applicant's Last Name Text
Enter the applicant's last name.
Max length: 50 characters
Applicant's First Name Text
Enter the applicant's first name.
Max length: 30 characters
Health Card Number Text
Enter the applicant's health card number.
Max length: 12 characters
Applicant's Last Name Text
Provide the applicant's last name.
Max length: 50 characters
Applicant's First Name Text
Provide the applicant's first name.
Max length: 30 characters
Health Card Number Text
Provide the applicant's health card number.
Max length: 12 characters
Applicant's Last Name Text
Provide the applicant's last name.
Max length: 50 characters
Applicant's First Name Text
Provide the applicant's first name.
Max length: 30 characters
Health Card Number Text
Provide the applicant's health card number.
Max length: 12 characters
Applicant's Gender
Male Checkbox
Check this box if the applicant identifies as male.
Female Checkbox
Check this box if the applicant identifies as female.
Other Checkbox
Check this box if the applicant identifies with a gender other than male or female.
Applicant's Other Gender Text
Provide a specific gender identity if the applicant's gender is neither Male, Female, Unknown, nor Undisclosed.
Unknown Checkbox
Check this box if the applicant's gender is not known.
Undisclosed Checkbox
Check this box if the applicant prefers not to disclose their gender.
Applicant's Information
Applicant's Last Name Text
Please enter the applicant's last name.
Max length: 50 characters
Applicant's First Name Text
Please enter the applicant's first name.
Max length: 30 characters
Health Card Number Text
Please enter the applicant's health card number.
Max length: 12 characters
Applicant's Mailing Address
Applicant's Mailing Address Unit Number Text
Enter the unit number of the applicant's mailing address.
Max length: 8 characters
Applicant's Mailing Address Street Number Text
Enter the street number of the applicant's mailing address.
Max length: 8 characters
Applicant's Mailing Address Street Name Text
Enter the street name of the applicant's mailing address.
Max length: 50 characters
Applicant's Mailing Address PO Box Text
Enter the PO Box number for the applicant's mailing address, if applicable.
Max length: 8 characters
Applicant's Mailing Address Lot Number Text
Enter the lot number of the applicant's mailing address.
Applicant's Mailing Address Concession Text
Enter the concession number or name for the applicant's mailing address.
Applicant's Mailing Address Rural Route Text
Enter the rural route number for the applicant's mailing address, if applicable.
Applicant's Mailing Address City/Town Text
Enter the city or town of the applicant's mailing address.
Max length: 50 characters
Applicant's Mailing Address Province Text
Enter the province of the applicant's mailing address.
Max length: 50 characters
Applicant's Mailing Address Postal Code Text
Enter the postal code of the applicant's mailing address.
Max length: 7 characters
Applicant's Name
Applicant's Last Name Text
Enter the applicant's last name.
Max length: 50 characters
Applicant's First Name Text
Enter the applicant's first name.
Max length: 30 characters
Applicant's Middle Initial Text
Enter the applicant's middle initial.
Max length: 3 characters
Applicant's Name and Health Card Number
Applicant's Last Name Text
Please enter the applicant's last name.
Max length: 50 characters
Applicant's First Name Text
Please enter the applicant's first name.
Max length: 30 characters
Health Card Number Text
Please enter the applicant's health card number.
Max length: 12 characters
Applicant's Personal and Health Card Details
Date of Birth Date
Please provide the applicant's date of birth.
Health Card Number Text
Please provide the applicant's health card number.
Max length: 12 characters
Health Card Version Code Text
Please provide the version code from the applicant's health card.
Max length: 2 characters
Health Card Expiry Date Date
Please provide the expiry date of the applicant's health card.
ARO Screening
ARO Screening Yes Checkbox
Check this box if an ARO screening has been completed for the applicant within the past 6 months.
ARO Screening No Checkbox
Check this box if an ARO screening has not been completed for the applicant within the past 6 months.
ARO Screening Not Known Checkbox
Check this box if it is not known whether an ARO screening has been completed for the applicant within the past 6 months.
ARO Action Taken and Additional Comments Text
Enter details regarding the action taken and any additional comments concerning the Antibiotic Resistant Organism (ARO) screening.
Max length: 5000 characters
As Required Oxygen Details
With Exertion / As Required Checkbox
Check this box if oxygen is used only during exertion or as required, rather than continuously.
As Required Oxygen Rate Number
Provide the oxygen flow rate in Liters per minute (L/min) when oxygen is used with exertion or as required.
Max length: 50 characters
Assistive Device Types and Specifications
Bi-level positive airway pressure system (BiPAP) Checkbox
Check this box if the applicant uses a Bi-level positive airway pressure system (BiPAP).
Continuous glucose monitors and supplies Checkbox
Check this box if the applicant uses continuous glucose monitors and related supplies.
Continuous positive airway pressure system (CPAP) Checkbox
Check this box if the applicant uses a Continuous positive airway pressure system (CPAP).
Insulin pump and supplies Checkbox
Check this box if the applicant uses an insulin pump and related supplies.
Power wheelchair Checkbox
Check this box if the applicant uses a power wheelchair.
Peritoneal dialysis equipment or supplies Checkbox
Check this box if the applicant uses peritoneal dialysis equipment and related supplies.
Bariatric wheelchair Checkbox
Check this box if the applicant uses a bariatric wheelchair.
Other Assistive Device Checkbox
Check this box if the applicant uses an assistive device not listed above and specify it in the 'Additional comments/specifications' field.
Other Assistive Device Type Text
Enter the name of the assistive device if it is not listed in the options provided.
Additional Comments or Specifications Text
Provide any additional comments or specifications regarding the medical devices and assistive or adaptive devices used by the applicant.
Max length: 5000 characters
Assistive Device Usage
Yes Checkbox
Check this box if the applicant uses any medical and/or assistive/adaptive device(s).
No Checkbox
Check this box if the applicant does not use any medical and/or assistive/adaptive device(s).
Not known Checkbox
Check this box if it is not known whether the applicant uses any medical and/or assistive/adaptive device(s).
Associated Pharmacy Information
Pharmacy Name Text
Please provide the full name of the associated pharmacy.
Pharmacy Telephone Number Text
Please provide the telephone number of the associated pharmacy.
Max length: 12 characters
Pharmacy Unit Number Text
Please provide the unit number for the associated pharmacy's address, if applicable.
Max length: 8 characters
Pharmacy Street Number Text
Please provide the street number for the associated pharmacy's address.
Max length: 8 characters
Pharmacy Street Name Text
Please provide the street name for the associated pharmacy's address.
Max length: 50 characters
Pharmacy PO Box Text
Please provide the PO Box number for the associated pharmacy's address, if applicable.
Max length: 8 characters
Pharmacy City/Town Text
Please provide the city or town where the associated pharmacy is located.
Max length: 50 characters
Pharmacy Province Text
Please provide the province where the associated pharmacy is located.
Max length: 50 characters
Pharmacy Postal Code Text
Please provide the postal code for the associated pharmacy's address.
Max length: 7 characters
Benzodiazepines Dependence
Benzodiazepines Dependence Checkbox
Check this box if the individual has a dependence on Benzodiazepines.
Cannabis Use Specification
Cannabis Checkbox
Check this box if the individual has a cannabis use disorder or dependence.
Cannabis Smoking Checkbox
Check this box if the individual's cannabis use involves smoking.
Cannabis Other Use Checkbox
Check this box if the individual's cannabis use involves methods other than smoking, such as vaping, eating, or drinking.
Cannabis Other Use Specification Text
Provide details on other forms of cannabis use, such as vaping, eating, or drinking.
Completing Practitioner's Designation
Physician Checkbox
Check this box if the practitioner completing the health assessment is a Physician.
Registered Nurse Checkbox
Check this box if the practitioner completing the health assessment is a Registered Nurse.
Registered Nurse (Extended Class) Checkbox
Check this box if the practitioner completing the health assessment is a Registered Nurse with an Extended Class designation.
Completing Practitioner's Name and Telephone Number
Completing Practitioner's Last Name Text
Enter the last name of the practitioner completing the health assessment.
Max length: 50 characters
Completing Practitioner's First Name Text
Enter the first name of the practitioner completing the health assessment.
Max length: 30 characters
Completing Practitioner's Telephone Number Text
Enter the telephone number of the practitioner completing the health assessment.
Max length: 12 characters
Continuous Oxygen Details
Continuous Checkbox
Check this box if oxygen is administered continuously.
Continuous Oxygen Amount Number
Enter the amount of continuous oxygen required.
Max length: 50 characters
Continuous Oxygen Rate Number
Enter the rate of continuous oxygen in liters per minute (L/min).
Max length: 50 characters
Current Medications
Current Medications - Cumulative Patient Profile Attached Checkbox
Check this box if the applicant's current medication information is included in the cumulative patient profile that is attached.
Current Medications - List Attached to Form Checkbox
Check this box if a list of the applicant's current medications is attached to this form.
Current Medications List Text
Provide a comprehensive list of the applicant's current medications, including prescription, non-prescription, and supplements, if a separate list is not attached.
Max length: 5000 characters
Discontinued Drugs Specification
Discontinued Drug 1 Text
Specify any specific drug that has been discontinued in the past 3 months.
Max length: 5000 characters
Fee Code
Fee Code Text
Provide the fee code for this health assessment.
Max length: 50 characters
Form Submission Information
Local Ontario Health atHome Office Text
Please enter the name of the local Ontario Health atHome office where the completed form should be returned.
Fax Number Text
Please enter the fax number for form submission.
Max length: 12 characters
General
Practitioner Information. Signature of Practitioner Signature
Save Form Button
Clear Form Button
Print Form Button
Mailing Address
Unit Number Text
Enter the unit number for the mailing address.
Max length: 8 characters
Street Number Text
Enter the street number for the mailing address.
Max length: 8 characters
Street Name Text
Enter the street name for the mailing address.
Max length: 50 characters
PO Box Text
Enter the Post Office Box number for the mailing address, if applicable.
Max length: 8 characters
Lot Number Text
Enter the lot number for the mailing address.
Concession Text
Enter the concession name or number for the mailing address, if applicable.
Rural Route Text
Enter the rural route number for the mailing address, if applicable.
City/Town Text
Enter the city or town for the mailing address.
Max length: 50 characters
Province Text
Enter the province for the mailing address.
Max length: 50 characters
Postal Code Text
Enter the postal code for the mailing address.
Max length: 7 characters
Medical Diagnoses
Cumulative patient profile is attached Checkbox
Check this box if the cumulative patient profile is attached.
Historical Medical Diagnoses Text
Provide a list of the applicant's active and relevant historical medical diagnoses.
Max length: 5000 characters
Nicotine Dependence Specification
Nicotine Dependence Checkbox
Check this box if the individual has nicotine dependence.
Smoking Checkbox
Check this box if the individual's nicotine dependence is due to smoking.
Other Nicotine Dependence Checkbox
Check this box if the individual's nicotine dependence is due to other forms like chewing tobacco, gum, or patch.
Nicotine Dependence Other Specification Text
Provide specific details regarding other forms of nicotine dependence, such as chewing tobacco, nicotine gum, or nicotine patches.
Ontario Health atHome Contact
Ontario Health atHome Contact Last Name Text
Please enter the last name of the Ontario Health atHome contact person.
Max length: 50 characters
Ontario Health atHome Contact First Name Text
Please enter the first name of the Ontario Health atHome contact person.
Max length: 30 characters
Ontario Health atHome Contact Telephone Number Text
Please enter the telephone number of the Ontario Health atHome contact person.
Max length: 12 characters
Ontario Health atHome Contact Telephone Extension Text
Please enter the telephone extension for the Ontario Health atHome contact person, if applicable.
Max length: 5 characters
Opioid Use Disorder Treatment Status
Yes Checkbox
Check this box if the applicant is currently on methadone maintenance treatment or receiving other treatment for Opioid Use Disorder.
No Checkbox
Check this box if the applicant is not currently on methadone maintenance treatment or receiving other treatment for Opioid Use Disorder.
Opioids Dependence
Opioids Checkbox
Check this box if the individual has an Opioids substance use disorder or dependence.
Other Substance Dependence
Other Checkbox
Check this box if the individual has a substance dependence on a substance not explicitly listed above, and then specify the substance in the provided space.
Other Substance Dependence Details Text
Provide details for the other substance dependence not listed.
Oxygen
Oxygen Yes Checkbox
Check this box if the applicant is receiving oxygen.
Oxygen No Checkbox
Check this box if the applicant is not receiving oxygen.
Oxygen Source
Tank Checkbox
Check this box if the oxygen source is a tank.
Concentrator Checkbox
Check this box if the oxygen source is a concentrator.
Unknown Oxygen Source Checkbox
Check this box if the type of oxygen source is unknown.
Prescribing Physician Information
Prescribing Physician Last Name Text
Enter the last name of the prescribing physician.
Max length: 50 characters
Prescribing Physician First Name Text
Enter the first name of the prescribing physician.
Max length: 30 characters
Prescribing Physician Telephone Number Text
Enter the telephone number of the prescribing physician.
Max length: 12 characters
Primary Care Provider Name
Primary Care Provider Last Name Text
Enter the last name of the primary care provider.
Max length: 50 characters
Primary Care Provider First Name Text
Enter the first name of the primary care provider.
Max length: 30 characters
Primary Care Provider Status Question
Yes Checkbox
Check this box if the practitioner completing the health assessment is the applicant's primary care provider.
No Checkbox
Check this box if the practitioner completing the health assessment is not the applicant's primary care provider, and the applicant has one.
No primary care provider Checkbox
Check this box if the applicant does not have a primary care provider.
Primary Care Provider Willingness to Continue Care
Yes Checkbox
Check this box if the primary care provider is willing to continue providing care after the applicant's admission into a long-term care home.
No Checkbox
Check this box if the primary care provider is not willing to continue providing care after the applicant's admission into a long-term care home.
Not known Checkbox
Check this box if it is unknown whether the primary care provider is willing to continue providing care after the applicant's admission into a long-term care home.
Responsive Behaviours
Wandering Checkbox
Check this box if the individual exhibits wandering behaviour in the last 12 months.
Physical Checkbox
Check this box if the individual exhibits physical responsive behaviours in the last 12 months.
Verbal Checkbox
Check this box if the individual exhibits verbal responsive behaviours in the last 12 months.
Sexual Checkbox
Check this box if the individual exhibits sexual responsive behaviours in the last 12 months.
None Checkbox
Check this box if the individual has not exhibited any responsive behaviours in the last 12 months.
Not Known Checkbox
Check this box if it is not known whether the individual has exhibited any responsive behaviours in the last 12 months.
Other (specify) Checkbox
Check this box if the individual exhibits other responsive behaviours not listed, and provide details.
Other Responsive Behaviour Text
Please specify any other responsive behaviour(s) not listed, observed in the last 12 months.
Risk Factor Screen Completion Status
Risk Factors Screen Completed Checkbox
Check this box if the Risk Factor Screen has been completed.
Risk Factors Unknown / Screen Not Completed Checkbox
Check this box if the Risk Factors are unknown or the Risk Factor Screen has not been completed.
Signature Date
Signature Date Date
Enter the date the signature was provided.
Status of Assessment
Status of Assessment. Initial Assessment CheckBox
Status of Assessment. Reassessment CheckBox
Date of Previous Assessment Date
Enter the date of the previous assessment submitted to Ontario Health atHome.
Status of Assessment. Has there been a change in the applicant’s health since that assessment? Yes (please complete Applicant Information and Practitioner Information sections and only applicable sections that reflect the change in the applicant's health since the previous assessment) CheckBox
Status of Assessment. Has there been a change in the applicant’s health since that assessment? No (please complete Applicant Information, Practitioner Information sections and sign the last page of the form) CheckBox
Substance Use Disorder Status
Substance Use Disorder(s) or Dependence. Does the individual have a substance use disorder, or substance dependence? Yes/Suspected CheckBox
No Checkbox
Check this box if the individual does not have a substance use disorder or substance dependence.
Symptom Development Status
Symptom Development Status: Yes Checkbox
Check this box if the applicant has developed new or worsening symptoms, requiring a chest x-ray and attachment of results.
Symptom Development Details Text
Enter details regarding chest x-ray results and any additional action taken if the applicant developed new or worsening symptoms.
Max length: 5000 characters
Symptom Development Status: No Checkbox
Check this box if the applicant has not developed new or worsening symptoms, and proceed to the Risk Factor Screen.
Symptom Screen Completion Status
Symptom Screen Completed Checkbox
Check this box if the symptom screen has been successfully completed for the applicant.
Symptom Screen Not Completed Checkbox
Check this box if the symptom screen has not been completed for the applicant.
TB Risk Factor Awareness
Risk Factor Awareness - Yes Checkbox
Check this box if you are aware of any risk factors for TB in the applicant, such as being born in/travelled to a TB endemic region, lived/worked/spent time in high exposure settings in Canada, previously stayed in a correctional facility or shelter, experienced homelessness/underhoused, or are a person who injects drugs/has a substance use disorder.
Risk Factor Awareness - No Checkbox
Check this box if you are not aware of any risk factors for TB in the applicant.
TB Risk Factor Details Text
Provide specific details of the identified TB risk factors for the applicant.
Max length: 5000 characters
Vaccination History
Vaccination Information in Patient Profile Checkbox
Check this box if the applicant's vaccination history information is included in the attached cumulative patient profile.
Date of Last Tetanus-Diphtheria (Td) Vaccine Date
Enter the date of the applicant's last Tetanus-Diphtheria (Td) vaccination.
Date of Last Tetanus-Diphtheria, Acellular Pertussis (Tdap) Vaccine Date
Enter the date of the applicant's last Tetanus-Diphtheria, acellular pertussis (Tdap) vaccination.
Date of Pneumococcal Vaccine Date
Enter the date of the applicant's last pneumococcal vaccination.
Date of Last COVID-19 Vaccine Date
Enter the date of the applicant's last COVID-19 vaccination.
Date of Last Flu Shot Date
Enter the date of the applicant's last flu shot vaccination.
Date of Last Respiratory Syncytial Virus (RSV) Vaccine Date
Enter the date of the applicant's last respiratory syncytial virus (RSV) vaccination.
Vacuum Assisted Closure Use
Vacuum Assisted Closure Use Yes Checkbox
Check this box if the applicant uses a Vacuum Assisted Closure (VAC) for a wound.
Vacuum Assisted Closure Use No Checkbox
Check this box if the applicant does not use a Vacuum Assisted Closure (VAC) for a wound.
Vacuum Assisted Closure Use Not known Checkbox
Check this box if it is not known whether the applicant uses a Vacuum Assisted Closure (VAC) for a wound.
Wound Care Specialist
Wound Care Specialist Yes Checkbox
Check this box if the applicant has a wound care specialist.
Wound Care Specialist No Checkbox
Check this box if the applicant does not have a wound care specialist.
Wound Care Specialist Not known Checkbox
Check this box if it is not known whether the applicant has a wound care specialist.
Wound Care Specialist Contact Information
Specialist Last Name Text
Enter the last name of the wound care specialist.
Max length: 50 characters
Specialist First Name Text
Enter the first name of the wound care specialist.
Max length: 30 characters
Specialist Telephone Number Text
Enter the telephone number of the wound care specialist.
Max length: 12 characters
Wound Information Declaration
Wounds. Information is included in the cumulative patient profile attached CheckBox
Wound Presence
Yes Checkbox
Check this box if the applicant has wounds.
No Checkbox
Check this box if the applicant does not have any wounds.
Not Known Checkbox
Check this box if it is not known whether the applicant has any wounds.
Wound Type
Post-surgical Checkbox
Check this box if the applicant has a wound that is post-surgical.
Pressure Ulcer Checkbox
Check this box if the applicant has a wound that is a pressure ulcer.
Diabetic Ulcer Checkbox
Check this box if the applicant has a wound that is a diabetic ulcer.
Other Checkbox
Check this box if the applicant has a wound type not listed above and provide details in the adjacent field.
Other Wound Type Text
Please specify the type of wound if it is not one of the listed options.