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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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