Follow the steps to complete the form online.

1. Click the ‘Get Form’ button to access the Elderaffairs State Fl Us form and open it in your preferred editing tool.
2. Begin by providing the purpose of the assessment. Indicate if the assessment is initial, annual, health, living situation, caregiver, environment, or income by checking the appropriate boxes.
3. Enter your Social Security number. Remember that providing this number is voluntary, and it will only be used for screening and referral purposes.
4. Fill in your name by providing your first name, middle initial (if applicable), and last name.
5. Input your Medicaid number, if you have one.
6. Enter your phone number for contact purposes.
7. Provide your date of birth in the format mm/dd/yyyy.
8. Select your sex by checking either Male or Female.
9. Mark your race and ethnicity by selecting all that apply from the provided options.
10. Indicate your primary language and whether you have limited ability to read, write, speak, or understand English.
11. Select your marital status from the available options.
12. Provide the current physical location address, including the street, city, ZIP code, and type of residence or facility.
13. If different, fill out your home address.
14. If different from your current location, complete your mailing address.
15. Enter the assessment date and referral date in the specified format.
16. Specify the referral source and any relevant details about transitioning out of a nursing facility.
17. Indicate if there is a primary caregiver and describe the living situation.
18. Provide your individual and couple monthly income as well as estimated total assets.
19. Indicate if you are receiving food assistance or need additional nutritional support.
20. Answer questions regarding the care you are receiving, your health status, and any assistance needed with daily tasks.
21. Review and provide information about current health conditions and therapies.
22. Detail the caregiver's information and their level of strain and confidence in providing care.
23. Complete the nutritional risk score section, answering questions about your eating habits and dietary needs.
24. Once all sections are completed, save your changes. You may choose to download, print, or share the completed form.

Start filling out the Elderaffairs State Fl Us form online today to ensure your information is processed smoothly.