Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to acquire the form and open it in your preferred online editor.
2. Begin filling out the resident's basic information, including their full name, address, sex, date of birth, and examination date.
3. Proceed to Section I: Medical History. Provide the primary diagnosis, details of any recent surgeries or acute illnesses, and any chronic illnesses along with physical or mental limitations.
4. Indicate any special dietary needs, the resident's weight and relevant opinions about it, as well as their blood pressure and any activity restrictions.
5. Note any required nursing care or medical examinations, including the frequency and necessity of doctors' visits or symptoms observation.
6. Move to Section II: Medications Needed. List the types of medications required, their frequency, and appropriate dosages.
7. In Section III: Observation of Individual, answer the questions regarding the individual’s mobility and health conditions, indicating 'Yes' or 'No' as required.
8. Finally, in Section IV: Evaluation, provide your professional opinion on whether the individual requires the support of an adult residential care setting, along with justification for any recommendations.
9. Ensure that the physician’s signature and the date are entered at the end of the form before proceeding to save, download, print, or share the completed document.

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