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

Enter any additional relevant information about the applicant’s medical diagnoses, advanced care planning, end-of-life preferences, or other notes that were not captured elsewhere on this form.

Enter any relevant details about the applicant’s substance use history (e.g., patterns of use, duration, substances involved, treatment history, current status, concerns or clarifications) to supplement the information provided elsewhere on this form.

Check this box when any documents or notes about the applicant's advance care planning or end-of-life care preferences are included with the form.

Enter any known information about the applicant’s advance care planning and/or end-of-life care preferences, directives, substitute decision maker, legal documents, or specific requirements relevant to their care.

Check this box when the practitioner discussed advance care planning or end-of-life care with a person or party not listed among Applicant, Applicant’s Family, Substitute Decision Maker, or Not known, and specify who on the provided line.

Enter the name(s) or relationship(s) of any other person(s) with whom the practitioner discussed the applicant's advance care planning or end-of-life care (e.g., 'neighbor - John Doe', 'friend', 'legal guardian'). Fill only if 'Other' is 'Yes'.

Check if the practitioner discussed advance care planning and/or end-of-life care with the applicant themself.

Check if the practitioner discussed advance care planning and/or end-of-life care with the applicant's family.

Check if the practitioner discussed advance care planning and/or end-of-life care with the substitute decision maker.

Check if it is not known who the practitioner discussed advance care planning and/or end-of-life care with.

Provide a full description of the applicant's known severe allergies, including allergen(s)/trigger(s), typical reactions and severity, dates or onset, whether an EpiPen/auto-injector is required or used, and any current treatment or management instructions. Fill only if 'Yes' is 'Yes'.

Check this box when the patient's cumulative patient profile containing their allergy information is included/attached to this form.

Check this box if the applicant does have one or more known severe allergies (for example drugs, food, latex, stinging insects/Hymenoptera).

Check this box if the applicant does not have any known severe allergies.

Check this box if it is unknown whether the applicant has any severe allergies.

Enter the applicant's date of birth.

Enter the applicant's Ontario health card number exactly as it appears on the card, including all digits.

Enter the health card's version code or letter (if present) exactly as shown on the card.

Enter the expiry date of the applicant's health card.

Check this box if the applicant's gender is male.

Check this box if the applicant's gender is female.

Check this box if the applicant's gender is other and write the specific gender in the adjacent space.

If the applicant's gender is not Male or Female, enter the applicant's gender identity or description here to specify the 'Other' option. Fill only if 'Other — please specify' is 'Yes'.

Check this box if the applicant's gender is unknown.

Check this box if the applicant chooses not to disclose their gender.

Enter the applicant's family/surname exactly as it appears on official documents.

Enter the applicant's given/first name as shown on official identification.

Enter the applicant's health card or insurance identification number used for medical records.

Enter the applicant's family or surname exactly as it appears on official documents.

Enter the applicant's given name (first name) exactly as it appears on official documents.

Enter the applicant's health card or insurance identification number as printed on their health card.

Enter the applicant's family or surname exactly as it appears on official documents.

Enter the applicant's given or first name exactly as it appears on official documents.

Enter the applicant's health card or insurance identification number as shown on their card.

Enter the applicant's family or surname exactly as it appears on official documents.

Enter the applicant's given or first name as shown on official identification.

Enter the applicant's health card or insurance number used by the issuing agency.

Enter the applicant's family or surname exactly as it appears on official documents.

Enter the applicant's given name (first name) exactly as it appears on official documents.

Enter the applicant's health card or insurance identification number as printed on their card or record.

Enter the applicant's family/surname exactly as it appears on their legal documents.

Enter the applicant's given/first name(s) as shown on their legal documents.

Enter the applicant's health card or insurance identification number as printed on their health card.

Enter the applicant's apartment, suite, or unit identifier (for example 'Apt 4B'); leave blank if not applicable.

Enter the numeric street or building number for the applicant's mailing address.

Enter the full street name and type (for example 'Main St' or 'Queen St W') for the applicant's mailing address.

Enter the post office box number if the applicant receives mail at a PO Box; leave blank if not applicable.

Enter the lot number from the property's legal description if applicable; leave blank if not applicable.

Enter the concession number or designation associated with the property if applicable.

Enter the rural route or rural delivery details (for example 'RR # and box') if applicable.

Enter the full name of the city, town, or municipality for the applicant's mailing address.

Enter the province or territory name or its standard abbreviation for the applicant's mailing address.

Enter the applicant's postal code (Canadian format, e.g., A1A 1A1) for the mailing address.

Enter the applicant's family or surname exactly as it appears on legal or medical records.

Enter the applicant's given or first name as shown on legal or medical records.

Enter the applicant's middle initial (single letter) or leave blank if none.

Check this box if an Antibiotic Resistant Organism (ARO) screening for the applicant has been completed within the past 6 months (attach results and provide any action taken). Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box if an ARO screening has not been completed for the applicant within the past 6 months. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box if it is unknown whether an ARO screening has been completed for the applicant within the past 6 months. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Enter any actions taken, follow-up steps, results summary and other relevant comments about the applicant's ARO screening in the past 6 months; include references to attached results as applicable. Fill only if 'ARO Screening (Past 6 Months) — Yes' is 'Yes'.

Enter the full name of the associated pharmacy (e.g., chain or independent pharmacy).

Enter the pharmacy's primary telephone number, including area code.

Enter the unit or suite number for the pharmacy address, if applicable.

Enter the street number (building/house number) of the pharmacy address.

Enter the full street name for the pharmacy address (e.g., Main St, Elm Avenue).

Enter the pharmacy's post office box number, if applicable.

Enter the city or town where the pharmacy is located.

Enter the province or state where the pharmacy is located.

Enter the pharmacy's postal code or ZIP code.

Check this box if there has been a change in the applicant's health since the previous assessment; complete the Applicant Information and Practitioner Information sections and any other sections that reflect the change.

Check this box if there has been no change in the applicant's health since the previous assessment; complete the Applicant Information and Practitioner Information sections and sign the last page of the form.

Check this box when the applicant's current medication information is provided by an attached cumulative patient profile.

Check this box when a separate list of the applicant's current medications is attached to the form.

Enter a comprehensive list of the applicant’s current medications, including prescription and non-prescription drugs, supplements, dosage, frequency, route, and any purpose or notes relevant to their care. Fill only if 'List of applicant’s current medications is attached to this form' is 'No'.

Enter the name(s) of any medication(s) discontinued in the past 3 months and provide relevant details such as dose, date discontinued, reason for discontinuation, prescriber (if known) and any additional notes about the change.

Enter the fee code assigned to this assessment as provided by the program or billing instructions (the short numeric or alphanumeric code used for billing).

Check this box if the applicant uses a Bi-level positive airway pressure system (BiPAP). Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Check this box if the applicant uses continuous glucose monitors and related supplies. Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Check this box if the applicant uses a continuous positive airway pressure system (CPAP). Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Check this box if the applicant uses an insulin pump and associated supplies. Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Check this box if the applicant uses a power wheelchair. Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Check this box if the applicant uses peritoneal dialysis equipment or related supplies. Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Check this box if the applicant uses a bariatric wheelchair. Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Check this box if the applicant uses a medical device not listed above, and specify the device on the provided line. Fill only if 'Medical Devices Used - Yes' is 'Yes'.

Enter the name and brief details of any medical, assistive, or adaptive device not listed above (e.g., make/model, supplies needed, or short description). Fill only if 'Other (specify)' is 'Yes'.

Enter any additional details about the applicant’s medical, assistive or adaptive devices—including device make/model, usage instructions, special specifications, precautions, actions taken, relevant dates, and any attached reports or supporting information. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when the applicant uses one or more medical and/or assistive/adaptive devices. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when the applicant does not use any medical and/or assistive/adaptive devices. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when it is unknown whether the applicant uses any medical and/or assistive/adaptive devices. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when the applicant's cumulative patient profile (cumulative medical record) is included with the form.

Enter the applicant's active and relevant historical medical diagnoses and related details (diagnosis name, approximate onset or diagnosis date, current status or severity, treating provider(s) and any relevant notes or context) to inform care needs; indicate if a cumulative patient profile is attached instead. Fill only if 'Cumulative patient profile is attached' is 'No'.

Check this box if the applicant is currently on methadone maintenance treatment or receiving any other treatment for Opioid Use Disorder.

Check this box if the applicant is not on methadone maintenance treatment and is not receiving any other treatment for Opioid Use Disorder.

Enter the Ontario Health atHome contact person's last (family) name.

Enter the Ontario Health atHome contact person's first (given) name.

Enter the primary telephone number for the Ontario Health atHome contact (include area code and any required formatting).

Enter the telephone extension for the contact if applicable, or leave blank if there is no extension.

Check this box if the applicant currently uses supplemental oxygen.

Check this box if the applicant does not use supplemental oxygen.

If the applicant uses oxygen, check this box when the oxygen source is a tank. Fill only if 'Oxygen — Yes' is 'Yes'.

If the applicant uses oxygen, check this box when the oxygen source is a concentrator. Fill only if 'Oxygen — Yes' is 'Yes'.

Check this box if the applicant uses oxygen but the type or source of the oxygen is unknown. Fill only if 'Oxygen — Yes' is 'Yes'.

Check this box if the applicant requires continuous (ongoing) oxygen therapy. Fill only if 'Oxygen — Yes' is 'Yes'.

Provide any detail about continuous oxygen therapy when applicable (for example 'Yes', hours per day, or other clarifying note). Fill only if 'Oxygen — Continuous' is 'Yes'.

Enter the oxygen flow rate in litres per minute used for continuous oxygen therapy. Fill only if 'Oxygen — Continuous' is 'Yes'.

Check this box if the applicant uses oxygen only with exertion or on an as‑needed basis (not continuously). Fill only if 'Oxygen — Yes' is 'Yes'.

Enter the oxygen flow rate in litres per minute prescribed for use with exertion or as required. Fill only if 'Oxygen — With Exertion / As Required' is 'Yes'.

Check this box if the practitioner who completed the health assessment is a physician.

Check this box if the practitioner who completed the health assessment is a registered nurse.

Check this box if the practitioner who completed the health assessment is a registered nurse of the extended class (RN(EC)).

Enter the last (family) name of the practitioner who completed the health assessment.

Enter the practitioner's first (given) name who completed the health assessment.

Enter the practitioner's telephone number where they can be reached, including area or country code if applicable.

Enter the practitioner's unit, apartment, or suite number for the mailing address (leave blank if none).

Enter the practitioner's street or civic number for the mailing address.

Enter the practitioner's street name (for example, Main St or King Avenue) for the mailing address.

Enter the practitioner's post office box identifier (PO Box) if mail should be delivered to a box instead of a street address.

Enter the lot number portion of the practitioner's rural or cadastral address, if applicable.

Enter the concession number or name used in the practitioner's rural address, if applicable.

Enter the practitioner's rural route or delivery route identifier (e.g., R.R. number), if applicable.

Enter the city, town, or municipality for the practitioner's mailing address.

Enter the province, state, or region for the practitioner's mailing address.

Enter the practitioner's postal code or ZIP code for the mailing address.

Enter the date when the practitioner signed the form.

Enter the last name (surname) of the prescribing physician who is providing or overseeing the applicant’s opioid use disorder treatment. Fill only if 'Methadone Maintenance or Other OUD Treatment - Yes' is 'Yes'.

Enter the first (given) name of the prescribing physician who is providing or overseeing the applicant’s opioid use disorder treatment. Fill only if 'Methadone Maintenance or Other OUD Treatment - Yes' is 'Yes'.

Enter the telephone number where the prescribing physician or their office can be reached (include area code and any necessary prefixes). Fill only if 'Methadone Maintenance or Other OUD Treatment - Yes' is 'Yes'.

Enter the last name (surname) of the applicant's primary care provider, if known; leave blank if not applicable. Fill only if 'No' is 'Yes'.

Enter the first (given) name of the applicant's primary care provider, if known; leave blank if not applicable. Fill only if 'No' is 'Yes'.

Check this box if the practitioner completing the health assessment is the applicant's primary care provider.

Check this box if the practitioner completing the health assessment is not the applicant's primary care provider.

Check this box if the applicant does not have a primary care provider.

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.

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.

Check this box if it is unknown whether the primary care provider will continue to provide care after the applicant’s admission into a long-term care home.

Provide a detailed description of the applicant's responsive behaviours in the last 12 months, including frequency, typical triggers, examples of incidents, observed patterns and any interventions or strategies used.

Check if the person has exhibited wandering (e.g., leaving safe areas, pacing, elopement) currently or at any time in the last 12 months.

Check if the person has exhibited physical behaviours (e.g., hitting, kicking, biting) currently or within the last 12 months.

Check if the person has exhibited verbal behaviours (e.g., shouting, threats, abusive language) currently or within the last 12 months.

Check if the person has exhibited sexually inappropriate or sexual behaviours (e.g., inappropriate touching, sexual advances) currently or within the last 12 months.

Check this box only if none of the listed behaviours have been observed in the last 12 months.

Check this box if it is not known whether the person has exhibited any of the listed behaviours in the last 12 months.

Check this box if the person exhibits other behaviours not listed and provide details in the accompanying 'Other (specify)' text field.

Enter any other current responsive behaviour(s) not listed above, providing a short label or description (e.g., specific behaviour type or example). Fill only if 'Other (specify)' is 'Yes'.

Enter the name or office identifier of the local Ontario Health atHome office to which the completed form should be returned.

Enter the fax number (including area code) for the office where the completed form should be sent.

Check this box when this is the first health assessment form you (the current practitioner) are completing for this applicant and you will complete all sections of the form.

Check this box when a previous health assessment for this applicant was already completed by you (the current practitioner) and you are submitting this form as a reassessment.

Enter the date when the previous health assessment was submitted to Ontario Health atHome. Fill only if 'Reassessment' is 'Yes'.

Check this box when the individual has an alcohol use disorder or dependence (or alcohol is suspected to be a substance of concern) as part of the substance use details. Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Check this box if the individual has a benzodiazepine substance use disorder or dependence (i.e., they use benzodiazepines problematically or meet criteria for dependence/suspected dependence). Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Check this box when the applicant has a cannabis use disorder or dependence (i.e., cannabis is a substance of concern). Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Check this box when the applicant uses the substance by smoking (selected as the route of use). Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Check this box when the applicant uses the substance by another route (for example vaping, eating, drinking) and provide details in the adjacent text field. Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Enter any other method(s) the individual uses to consume cannabis (for example: vaping, edibles, drinking, topical), providing a short free-text description of the method(s). Fill only if 'Yes/Suspected', 'Other (e.g., vaping, eating, drinking)' is 'Yes/Suspected' and is 'Yes' (all).

Check this box when the individual has a diagnosed or suspected nicotine dependence/substance use disorder. Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Check this box when the individual's nicotine use is by smoking (e.g., cigarettes, cigars). Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Check this box when the individual's nicotine use is by other methods (e.g., chewing tobacco, nicotine gum, patch) and provide specifics on the line provided. Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Enter the specific other form of nicotine use (for example, chewing, nicotine gum, patch, or a short descriptive detail) to specify how the applicant uses nicotine. Fill only if 'Yes/Suspected', 'Other (e.g., chewing, gum, patch)' is 'Yes/Suspected' and is 'Yes' (all).

Check this box if the individual has (or is suspected to have) an opioid use disorder or opioid dependence. Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Check this box when the individual has a substance use disorder or dependence for a substance not listed (write the specific substance on the provided line). Fill only if 'Yes/Suspected' is 'Yes/Suspected'.

Enter the name(s) of any other substance(s) used that are not listed above; provide specifics such as substance type and any brief details (e.g., route or form) as space allows. Fill only if 'Yes/Suspected', 'Other (specify)' is 'Yes/Suspected' and is 'Yes' (all).

Check this box if the individual has a known substance use disorder or is suspected to have one (including alcohol, nicotine, or other substances).

Check this box if the individual does not have and is not suspected to have any substance use disorder or dependence.

Check this box when the TB risk factor screening has been completed for the applicant. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when the TB risk factor status is unknown or the risk factor screen was not completed. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when you are aware of one or more risk factors for tuberculosis in the applicant and will provide the specification(s) below. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when you are not aware of any risk factors for tuberculosis in the applicant. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Enter a concise list or description of any tuberculosis risk factors present for the applicant (for example: travel to a TB-endemic region, prior incarceration or shelter stay, homelessness/underhoused, history of injection drug use, or other known exposure). Fill only if 'TB Risk Factors Present — Yes' is 'Yes'.

Check this box when the TB symptom screen has been completed for the applicant. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box when the TB symptom screen has not been completed for the applicant. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Check this box if the applicant has developed new or worsening TB symptoms and a chest x‑ray is required (attach results and note any additional actions taken). Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Enter the chest x‑ray results and any additional actions taken (e.g., attach results, referrals, treatment or follow‑up instructions) when TB symptoms are present. Fill only if 'Yes – Chest x-ray required' is 'Yes'.

Check this box if the applicant has not developed new or worsening TB symptoms (or symptoms were present but testing was negative) and you should proceed to the Risk Factor Screen. Fill only if 'Initial Assessment' is 'Yes' or 'Has there been a change in the applicant’s health since that assessment?' is 'Yes'.

Enter the date the applicant last received the Tetanus‑Diphtheria (Td) vaccine.

Enter the date the applicant last received the Tdap (Tetanus‑Diphtheria, acellular pertussis) vaccine.

Enter the date the applicant last received a pneumococcal vaccine.

Enter the date the applicant last received any COVID‑19 vaccination.

Enter the date the applicant most recently received an influenza (flu) vaccination.

Enter the date the applicant last received a respiratory syncytial virus (RSV) vaccine.

Check this box when the applicant's vaccination information is included in the attached cumulative patient profile.

Enter any additional details about the applicant's wounds such as history and duration, wound location(s), stage/severity of injury, current wound care treatments and frequency, required specialty supplies, and any other relevant notes.

Check this box if the applicant currently has one or more wounds.

Check this box if the applicant does not currently have any wounds.

Check this box if it is unknown whether the applicant currently has any wounds.

Check this box when wound-related information for the applicant is documented in and attached as part of the cumulative patient profile.

Check this box if the applicant has a post-surgical wound (a wound resulting from a recent surgical procedure). Fill only if 'Wounds - Yes' is 'Yes'.

Check this box if the applicant has a pressure ulcer (a bedsore caused by prolonged pressure on the skin). Fill only if 'Wounds - Yes' is 'Yes'.

Check this box if the applicant has a diabetic ulcer (a wound related to diabetes, commonly on the feet or lower extremities). Fill only if 'Wounds - Yes' is 'Yes'.

Check this box if the applicant has a wound type not listed above and write the specific wound type on the provided line. Fill only if 'Wounds - Yes' is 'Yes'.

Enter the specific wound type when it is not listed among the provided options (e.g., laceration, abrasion, infected wound); provide a short descriptive label. Fill only if 'Wounds - Yes', 'Other (specify)' is 'Yes' (all).

Check this box if the applicant currently uses a Vacuum Assisted Closure (VAC) device for a wound.

Check this box if the applicant does not use a Vacuum Assisted Closure (VAC) device for a wound.

Check this box if it is unknown whether the applicant uses a Vacuum Assisted Closure (VAC) device for a wound.

Enter the wound care specialist's or clinic's last name or surname as known. Fill only if 'Wound Care Specialist - Yes' is 'Yes'.

Enter the wound care specialist's given name or the clinic contact first name. Fill only if 'Wound Care Specialist - Yes' is 'Yes'.

Provide the primary telephone number to contact the wound care specialist or clinic. Fill only if 'Wound Care Specialist - Yes' is 'Yes'.

Check this box if the applicant has a wound care specialist.

Check this box if the applicant does not have a wound care specialist.

Check this box if it is unknown whether the applicant has a wound care specialist.