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Initial Assessment Form
CLIENT'S INFORMATION
Gender
Male
Female
PERSON FILLING UP FORM
SCHEDULE NEEDED
Days needed
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Caregiver Preference:
Male
Female
Any
ASSESSMENT QUESTIONAIRE
Food Allergies
Yes
No
Client living alone?
Yes
No
Medical History
Dementia
COPD
Hypertension
CHF (Congestive Heart Failure)
Diabetes
Renal Failure
Stroke
Parkinsons Disease
Others:
Medications:
Yes
No
Does the client have a history of falls?
Yes
No
Does the client have any wound or sores?
Yes
No
Does the client have any bruising?
Yes
No
Does the client have any swelling or redness?
Yes
No
Can the client walk?
with assistance
without assistance
Is lifting required?
Yes
No
Does the client uses any of the following?
Cane
Walker
Wheelchair
None
Does the client have regular bowel movement?
Yes
No
Incontinent
Does the client have/uses:
Foley Catheter
Colostomy
Diapers
Bed Pads (chucks)
Bedside Commode
Urinal
Does the client need assistance in feeding?
Yes
No
Does the client need assistance meal preparation??
Yes
No
Does the client need assistance in light housekeeping?
Yes
No
Can the client stand up?
with assistance
without assistance
Medical equipment/s client uses
Home oxygen
Hospital bed (bedridden)
Nebulizer
Glucometer
Does the client able to tell when to pee?
Yes
No
Incontinent
Cognitive Ability:
Alert
Oriented
Forgetful
On & Off Confusion
Does the client have a history to strike out?
Yes
No
Does the client need assistance in bathing?
Yes
No
Does the client need assistance in laundry?
Yes
No
MISCELLANEOUS
Are there any pets in the house?
Yes
No
How would you like us to contact you?
Phone Call
Text
Email
Submit
Thanks for submitting!
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