Initial Assessment Form
CLIENT'S INFORMATION
Gender
PERSON FILLING UP FORM
SCHEDULE NEEDED
Days needed
Caregiver Preference:
ASSESSMENT QUESTIONAIRE
Food Allergies
Client living alone?
Medical History
Medications:
Does the client have a history of falls?
Does the client have any wound or sores?
Does the client have any bruising?
Does the client have any swelling or redness?
Can the client walk?
Is lifting required?
Does the client uses any of the following?
Does the client have regular bowel movement?
Does the client have/uses:
Does the client need assistance in feeding?
Does the client need assistance meal preparation??
Does the client need assistance in light housekeeping?
Can the client stand up?
Medical equipment/s client uses
Does the client able to tell when to pee?
Cognitive Ability:
Does the client have a history to strike out?
Does the client need assistance in bathing?
Does the client need assistance in laundry?
MISCELLANEOUS
Are there any pets in the house?
How would you like us to contact you?

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