Adult activity pages printable

    • [PDF File]STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY ...

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      APPLICATION FOR CALFRESH , CASH AID , AND/OR MEDI-CAL/HEALTH CARE PROGRAMS ... you must fill out questions 1 through 5 on pages 1 and 2 of the application and sign it to begin the application ... school, or participating in a required work activity. • Child support paid by a person in your household.

    • [PDF File]Adverse Childhood Experience (ACE) Questionnaire Finding ...

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      Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score ra hbr 10 24 06 While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often … Swear at you, insult you, put you down, or humiliate you?

    • [PDF File]SS-4 Application for Employer Identification Number

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      Form SS-4 (Rev. December 2017) Department of the Treasury Internal Revenue Service . Application for Employer Identification Number (For use by employers, corporations, partnerships, trusts, estates, churches,

    • [PDF File]Mini-Mental State Examination

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      response within each question or activity. Maximum Score Patient’s Score Questions 5 “What is the year? Season? Date? Day of the week? Month?” 5 “Where are we now: State? County? Town/city? Hospital? Floor?” 3 The examiner names three unrelated objects clearly and slowly, then asks the patient to name all three of them.

    • [PDF File]State Operations Manual

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      rooms, activity rooms, outdoor areas, and meeting rooms where residents are located on a regular basis. Composite distinct part. (1) Definition. A composite distinct part is a distinct part consisting of two or more non-contiguous components that are not located within the same campus, as defined in §413.65(a)(2) of this chapter. (2) Requirements.

    • [PDF File]IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM HEALTH CARE ...

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      unable to perform some activity of daily living independently and without IHSS the individual would be at risk of placement in out-of-home care. This health care certification form must be completed and returned to the IHSS worker listed above. The IHSS worker will use the information provided to evaluate the individual’s

    • [PDF File]Berg Balance Scale - Brandeis University

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      Berg Balance Scale continued….. 8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward.

    • [PDF File]Function Report - Adult

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      FUNCTION REPORT - ADULT - Form SSA-3373-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM IF YOU NEED HELP If you need help with this form, complete as much of it as you can and call the phone number provided on the letter sent with the form, or contact the person who asked you to complete the form.

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