of Max Body Width Known Mobility
Obesity Risk Assessment Form 1 Date ProspectivecompletedResident Name_________________________________ Proposed Room placement
Body Size Information
Site Needs:
WeightHeight BMI (CDC BMI Calculator) Max Body Width
MDS ADL’s:
Independent or Limited Assistance: Resident highly involved in the activity; may receive physical help guiding movement of limbs, other non weight bearing assistance 3 or more times or combination of non-weight bearing help with more help provided only 1 or 2 times during period (for a total of 3 or more episodes of physical help).
Extensive or Total Assistance: Resident received at least help in the activity 3 or more times including weight bearing support or full performance by another during part (but not all) of last 3 days
Activity Independent or Limited Assistance Extensive or Total Assistance Notes Bed Mobility ☐ ☐ Transfer ☐ ☐ Walk in Room ☐ ☐ Walk Corridorin ☐ ☐ Locomotion on Unit ☐ ☐ Dressing ☐ ☐ Toilet Use ☐ ☐ PersonalHygiene ☐ ☐
Definitions:
Obesity Risk Assessment Form 2
Pressure Ulcer No / Yes
PICC Line/IV Line No / Yes No / Yes
☐ ☐
No
☐
Hip/Knee/ShoulderReplacement ☐ ☐
Incontinence ☐ ☐
☐ ☐
Obesity Risk Assessment Form 3
Obesity
☐ ☐
BiPAP/CPAP No / Yes No / Yes
☐ ☐
☐
☐ ☐
☐ ☐
Any Fall No / Yes No / Yes
☐ ☐
Heart Failure ☐ No / Yes
Bladder No / Yes
Skin Infection No / Yes
Severe Lymphedema or Edema No / Yes
History in Last Year Yes Will TreatmentCompromiseObesityRoutinePlan Adaptation Plan
Bowel Incontinence No / Yes
Tracheotomy ☐ ☐
Key Medical History:
Deep Vein Thrombosis / Pulmonary Embolism ☐ No / Yes
☐ ☐
☐ ☐
Urinary Tract Infection No / Yes
Supplemental Oxygen ☐ ☐
Wounds needing therapy No / Yes
Gown Size L / XL / XXL
Equipment Needs: (see Obesity Equipment Decision Guide)
Bedside Recliner Width (inch) 19 / 22 / 25 / 32
Mattress Type
Wheelchair Size (inch) 28 / 34 / 48
Walker Size (inch) 25 / 36 / 42
Hoyer Lift Needed No / Yes Max Capacity:
Commode Size (inch) 26 / 36 / 46
Equipment Type Common size options
Foam / Low Air Loss / Alternating Pressure
Hoyer Sling Size M (to 210) / L (to 350) / XL ( to 500) / XXL
Bed Width (inch) 36 / 39 / 42 / 48 / 54 / 60
Bed Length (inch) 75 / 80 / 84
Sock Size L / XL / XXL
Undergarment Size L / XL / XXL
Obesity Risk Assessment Form 4
Does bariatric bed fit in available room ☐ Yes / No
Does your preferred transportation / ambulance company provide services for a resident this size?
Will wide wheelchair fit for toilet transfers Yes / No
☐ ☐
☐ ☐
Does bariatric chair fit in available room Yes / No
Obesity Risk Assessment Form 5
Does bariatric commode fit in available room Yes / No
☐
Will toilet and grab bars be rated to body weight Yes / No
☐ ☐
Room Needs:
Therapy Needs:
☐ ☐
What PT / OT / Rehab services are needed?
Transportation Needs:
☐ ☐
Will wide wheelchair fit for transfer Yes / No
Yes No Is a more suitable room available
Obesity Risk Assessment Form
How practical is emergency evacuation of this resident from the available room?
Discharge Planning:
How accessible is the resident’s home to necessary bariatric size equipment (wheelchair, bed, etc.)?
Evacuation Planning:
6