ࡱ> '` bjbj{P{P w`::}Fe rrr8d 3j(x d4((((9(dHh$khm(h|(hi%%%d(%(%%:, @+r{E j03jOR;nO~ ;n;n$4"V%n444(h(h X4443j   inV   n    NJ Department of Human Services - Division of Developmental Disabilities ADAPTIVE BEHAVIOR SUMMARY (ABS) This form is intended to capture information that accurately reflects an individuals functional abilities. It can be used for an individual applying for DDD eligibility or as necessary for an individual who is eligible to receive DDD services. It should be completed by someone who knows the individual, such as a family member, caregiver or case manager. Please print the information you provide, and complete and sign the ABS Acknowledgement Form at the end.  Name of Individual: FORMTEXT       Individual is (check one): FORMTEXT      Applying for DDD Eligibility FORMTEXT      DDD Eligible ABS Completed by: FORMTEXT      Date: FORMTEXT       Relationship to Individual: FORMTEXT      Phone # FORMTEXT       Individual s address: FORMTEXT      Phone # FORMTEXT       FORMTEXT       FORMTEXT       Is this a residential program? FORMTEXT      Yes FORMTEXT      No/ If yes, please complete: Placement Type: FORMTEXT      Phone# FORMTEXT       Provider: FORMTEXT       Does individual attend school or a day program? FORMTEXT      Yes FORMTEXT      No/ If yes, please complete: School or Day Program type FORMTEXT      Phone # FORMTEXT       School Name or Provider: FORMTEXT      Address: FORMTEXT       FORMTEXT       Medicaid # FORMTEXT      Private Insurance: FORMTEXT      Medicare # FORMTEXT      Private Insurance Policy # FORMTEXT       Guardian or Parent (Please circle one): FORMTEXT       Address FORMTEXT      Phone: FORMTEXT       FORMTEXT       Emergency Contacts: Name: FORMTEXT      Relationship: FORMTEXT      Phone # FORMTEXT      Address: FORMTEXT       Name: FORMTEXT      Relationship: FORMTEXT      Phone # FORMTEXT      Address: FORMTEXT       For DDD Use Only: Case Manager: _______________________________________ Phone #:___________________ MIS Number: ________________________________________  Independent Needs to be reminded Needs verbal direction Needs Physical Assistance No opportunity To observeCommentsI. SELF-HELP SKILLS (Check appropriate boxes) A. Eating FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      1. Feeds self with a spoon2. Feeds self with a fork FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      3. Cuts food with a knife FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      4. Eats with fingers FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      5. Drinks from cup or glass FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       6. Are G-tube feedings given?  FORMCHECKBOX  yes  FORMCHECKBOX  no 7. Is any adaptive feeding equipment used?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes, specify:  FORMTEXT       8. Is this person on a special diet?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes, what kind?  FORMCHECKBOX  low salt  FORMCHECKBOX  low sugar  FORMCHECKBOX  low cholesterol  FORMCHECKBOX  chopped food  FORMCHECKBOX  pureed food  FORMCHECKBOX  other:  FORMTEXT       Is this a physician s recommendation?  FORMCHECKBOX  yes  FORMCHECKBOX  no 9. If any foods must be avoided because of allergies, digestive problems, religious considerations, or dislikes, please list:  FORMTEXT       10. Any favorite foods?  FORMTEXT       B. Toileting 11. Does this person wear diapers:  FORMCHECKBOX  yes:  FORMCHECKBOX  day  FORMCHECKBOX  night  FORMCHECKBOX  no If the individual always wears diapers, you can skip to C. Hygiene.  Independent Needs to be reminded Needs verbal direction Needs Physical Assistance No opportunity To observeComments12. Toilets self FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      a) Wipes self with toilet paper.b) Washes hands after toileting. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      c) (Women) Takes care of menstrual needs. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       13. Appropriate toilet habits?  FORMCHECKBOX  yes  FORMCHECKBOX  no If no, specify:  FORMTEXT       14. Any bladder accidents?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes,  FORMCHECKBOX  day  FORMCHECKBOX  night: (how often)  FORMTEXT       15. Any bowel accidents?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes,  FORMCHECKBOX  day  FORMCHECKBOX  night: (how often)  FORMTEXT       C. Hygiene 16. Washing and Bathing  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      a) Washes and dries handsb) Washes and dries face FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      c) Bathes self in bathtub FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      d) Showers self FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Turns on and regulates water temperature FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      f) Washes hair  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      g) Dries self FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      17. Uses deodorant  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT        Independent Needs to be reminded Needs verbal direction Needs Physical Assistance No opportunity To observeComments18. Combs/brushes hair FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      19. Tooth and mouth care FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      a) Puts toothpaste on brush b) Brushes own teeth FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      20. Dentures FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      a) Worn regularlyb) Cares for own dentures FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      21. Blows and wipes nose with tissue FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      22. Shaving FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       Usually uses:  FORMCHECKBOX  safety razor  FORMCHECKBOX  electric razor D. Dressing Skills 23. Undresses self FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      24. Buttons FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      25. Snaps FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      26. Zippers FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      27. Fastens a buckle FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      28. (Women) Hooks own bra FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      29. Ties shoes FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      30. Dresses self completely FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      31. Changes clothing regularly FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      32. Matches colors/patterns FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       33. Selects seasonal clothing FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       Additional Comments: (Is there other information or any specialized needs or particular concerns that this consumer has?  FORMTEXT       Is there anything that could cause a danger to this consumer, i.e. stairs, food consistency, allergies, etc.?  FORMTEXT       II. COMMUNICATION SKILLS: 34. 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Understands the spoken word?  FORMCHECKBOX  yes  FORMCHECKBOX  no 36. Follows simple directions?  FORMCHECKBOX  yes  FORMCHECKBOX  no 37. Any hearing problems?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes, describe:  FORMTEXT       38. Communicates through: a) verbal speech  FORMCHECKBOX  yes  FORMCHECKBOX  no b) communication device  FORMCHECKBOX  yes  FORMCHECKBOX  no c) gestures  FORMCHECKBOX  yes  FORMCHECKBOX  no d) signs  FORMCHECKBOX  yes  FORMCHECKBOX  no Gestures and signs known and used:  FORMTEXT       39. Telephone Usage: a) Can dial the phone  FORMCHECKBOX  yes  FORMCHECKBOX  no b) Can speak on the phone  FORMCHECKBOX  yes  FORMCHECKBOX  no 40. Can this person read?  FORMCHECKBOX  yes  FORMCHECKBOX  no 41. Can this person write?  FORMCHECKBOX  yes  FORMCHECKBOX  no III. SOCIAL BEHAVIORS 42. What does this person enjoy doing?  FORMTEXT       43. How are emotions such as anger or frustration displayed?  FORMTEXT       44. Is this person sexually active?  FORMCHECKBOX  yes  FORMCHECKBOX  no Comments:  FORMTEXT       45. How are symptoms of illness communicated?  FORMTEXT       46. Does this person smoke?  FORMCHECKBOX  yes  FORMCHECKBOX  no 47. Are there any unusual fears? (List)  FORMTEXT       48. Does this person: a) Wander off if not closely supervised?  FORMCHECKBOX  yes  FORMCHECKBOX  no b) Run away?  FORMCHECKBOX  yes  FORMCHECKBOX  no c) Have any unusual sleep patterns?  FORMCHECKBOX  yes  FORMCHECKBOX  no Describe:  FORMTEXT       49. Can this person be in a home with children?  FORMCHECKBOX  yes  FORMCHECKBOX  no 50. Is this person: a) self-abusive?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes, how?  FORMTEXT       b) abusive to others?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes, how?  FORMTEXT       c) destructive to property?  FORMCHECKBOX  yes  FORMCHECKBOX  no If yes, how?  FORMTEXT       IV. COMMUNITY AWARENESS 51. What community activities are enjoyed?  FORMTEXT      . 52. Does the person demonstrate appropriate behavior during these activities?  FORMCHECKBOX  yes  FORMCHECKBOX  no If no, comment:  FORMTEXT       53. Is this person aware of ordinary household dangers, such as stairs, heaters, electric outlets, household cleaners, ovens, wood burning stoves and fireplaces?  FORMCHECKBOX  yes  FORMCHECKBOX  no  FORMCHECKBOX  no opportunity to observe If no, specify:  FORMTEXT       54. Does this person demonstrate awareness of community dangers, including traffic, being overly friendly with strangers, etc.?  FORMCHECKBOX  yes  FORMCHECKBOX  no  FORMCHECKBOX  no opportunity to observe If no, specify:  FORMTEXT       55. Can the consumer count change/make purchases?  FORMCHECKBOX  yes  FORMCHECKBOX  no  FORMCHECKBOX  only under supervision 56. Can this person tell time?  FORMCHECKBOX  yes  FORMCHECKBOX  no V. PHYSICAL CONDITIONS, LIMITATIONS, AND ASSISTIVE DEVICES Please check all the medical problems or related conditions that you are aware of: Current History of Problem a) Asthma  FORMCHECKBOX   FORMTEXT       b) Diabetes  FORMCHECKBOX   FORMTEXT       c) Frequent colds  FORMCHECKBOX   FORMTEXT       d) Pneumonia  FORMCHECKBOX   FORMTEXT       e) Lung/breathing problems  FORMCHECKBOX   FORMTEXT       f) Hay fever  FORMCHECKBOX   FORMTEXT       g) Ear infections  FORMCHECKBOX   FORMTEXT       h) Frequent headaches  FORMCHECKBOX   FORMTEXT       i) Serious skin problems  FORMCHECKBOX   FORMTEXT       j) Gum problems  FORMCHECKBOX   FORMTEXT       k) Dental problems  FORMCHECKBOX   FORMTEXT       l) Hypertension  FORMCHECKBOX   FORMTEXT       m) Heart/circulatory problems  FORMCHECKBOX   FORMTEXT       n) Stomach/digestive problems  FORMCHECKBOX   FORMTEXT       o) Kidney/Urinary problems  FORMCHECKBOX   FORMTEXT       p) Pica (eats inedible items)  FORMCHECKBOX   FORMTEXT       q) Hepatitis B carrier  FORMCHECKBOX   FORMTEXT       r) Seizure disorder  FORMCHECKBOX   FORMTEXT       (check type which affects consumer):  FORMCHECKBOX  loss of consciousness / Grand Mal  FORMCHECKBOX  absence, or staring episodes / Petit Mal  FORMCHECKBOX  tremors  FORMCHECKBOX  other:  FORMTEXT       s) Other medical problems (List):  FORMTEXT       58. Is this person visually impaired?  FORMCHECKBOX  yes  FORMCHECKBOX  no 59. Check which of the following best describes mobility:  FORMCHECKBOX  Walks independently, with or without physical aids. Describe assistance, if needed:  FORMTEXT        FORMCHECKBOX  Primarily uses a wheelchair, but can move and transfer in and out of it independently.  FORMCHECKBOX  Can move the wheelchair independently but needs assistance with transfers.  FORMCHECKBOX  Non-mobile, totally dependent. 60. Height:  FORMTEXT       Weight:  FORMTEXT       61 Please indicate which of the following the person owns and uses:  FORMCHECKBOX  Manual wheelchair  FORMCHECKBOX  Eyeglasses  FORMCHECKBOX  Motorized wheelchair  FORMCHECKBOX  Hearing Aid  FORMCHECKBOX  Stroller  FORMCHECKBOX  Helmet  FORMCHECKBOX  Walker  FORMCHECKBOX  Scoliosis jacket  FORMCHECKBOX  Crutches  FORMCHECKBOX  Elastic Stockings  FORMCHECKBOX  Cane  FORMCHECKBOX  Braces (AFO, KAFO, etc.)  FORMCHECKBOX  Corrective Shoes  FORMCHECKBOX  Dental appliances  FORMCHECKBOX  Car seat  FORMCHECKBOX  Other (list):  FORMTEXT       62. Please list all medications taken on a regular basis: Medication Dosage/Times taken Prescribed by To control  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       63. Method of administering medications (Describe how independent the consumer is in administering his/her own medications:  FORMTEXT       64. Allergies to any medication?  FORMCHECKBOX  no  FORMCHECKBOX  yes, Specify:  FORMTEXT       65. 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