Intake Screening and Assessment Paper

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Client-Assessment-Form-in-PDF.zip

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Client Assessment Form in PDF.pdf

ABC Home Care

Company

Logo

CLIENT ASSESSMENT FORM

Personal Information Date:

First Name

Middle Initial

Last Name

Address

City

State

Zip Code

Telephone

Birth Date

______/_______/________ MM DD YYYY

Age

Gender

M F

Height

Weight

Hair Color

Assessment Performed By

Other Parties Present / Title (i/e: family members, Care Manager)

Marital Status Date of spouse’s death

Single Married Divorced Separated Widowed Legal Status

Responsible for Self Power of Attorney Guardian DNR Order – Location:

Name: Phone Number:

Medical Contact Information

Primary Care Physician

Telephone

Hospital Name & Address

Telephone

Specialist Physician (Specify)

Telephone

Hospital Name & Address

Telephone

Emergency Contact Information

Emergency Contact 1

Relationship

Address

City

State

Zip

Telephone

Emergency Contact 2

Relationship

Address

City

State

Zip

Telephone

C L I E N T : P a g e | 2

Living Situation Current Living Situation & Conditions

Significant Events (Recent or Past)

Disability History (When did activities become more difficult)

Originally From?

Length of time at current home?

Other In-Home Providers? (Name | Service | Phone #)

NOTES

Any Children?

Is Family/Children in the Area?

Visitation Frequency

Any Pets? (Animal Type & Names)

Care Required for Pets?

Veterinarian Contact Info

Activities Hobbies

Previous Career/Occupation

Favorite Activities Currently Doing

Favorite Activities But Can’t Do

Ongoing Social Activities

Clubs/Organization Membership

Friends & Visitors

Visitation Frequency

DRIVING

Currently able to drive

Vehicle Registration current?

YES NO

Unable to drive: (check ONE below)

Client’s car used for Transportation

Caregivers car used for Transportation

Auto Insurance Company

Policy #

Date of last service

C L I E N T : P a g e | 3

Functional Assessment

Levels of Assistance: 0=Independent – Completes the task independently

3=Minimum Assistance – Occassional assistance or supervision may be necessary

6=Moderate Assistance – Assistance or supervision is always necessary

9=Maximum Assistance – Totally dependent on others

1. For each activity check the box indicating the assistance needed. 2. If assistance is needed, indicate the source of help (be specific: spouse, family, friend, paid help, volunteer, professional) 3. In the comments indicate the type of assistance provided and how often it’s provided. Indicate if client needs further help.

ACTIVITIES OF DAILY LIVING

Activity

Ind.

Min.

Assist

Mod.

Assist

Max

Assist

Primary

Source of Help Comments / Other Sources

Eating

Bathing

Grooming

Dressing

Toileting

Mobility

Transferring

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

Activity

Ind.

Min.

Assist

Mod.

Assist

Max

Assist

Primary

Source of Help Comments / Other Sources

Laundry

Meal Preparation

Light Housework

Heavy Housework

Shopping/Errands

Transportation

Medication Mgmt

Adaptive Equipment

Has

Has but

Doesn’t

Use

Needs

Comments

Cane/Crutches/Walker

Wheelchair (manual / power)

Toilet Equip. (commode / seat)

Bathing Equip (seat / grab bars)

Hospital Bed (power / manual)

Hoyer Lift (power / manual)

Other:

Dentures

Diabetic Supplies

Incontinence Products

Medical Phone Alert

Other:

C L I E N T : P a g e | 4

Medical Diagnosis

Diagnosed medical conditions/diseases

Memory (describe)

Dementia

Alzheimer’s

Wanders

Uses electronic alert system

Company:

Other

Drug Use/Abuse (describe)

Prescription Medications Pharmacy Location

Phone #

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Prescription

Dosage

Time to Take

Doctor

Over the Counter Medications Medication

Dosage

Frequency

Notes

Medication

Dosage

Frequency

Notes

Medication

Dosage

Frequency

Notes

Medication

Dosage

Frequency

Notes

Pharmacy Location

Phone #

Medication Notes

C L I E N T : P a g e | 5

Nutrition Typical Current Meals

Breakfast

Lunch

Dinner

Snacks

Favorite Foods:

Eats fewer than 2 meals per day YES NO Special Notes/ Nutrition Concerns

Eats few fruits, vegetables or milk products YES NO

Drinks beer, wine or liquor daily/regularly YES NO

Has tooth or mouth problems that makes it difficult to eat YES NO

Has gained/lost 10 pounds in past 6 months YES NO

Sleep Patterns Wakes

Bedtime

Daytime Naps

Nocturnal Wakening

Fall Risk Screening 1. How many times have you fallen in the past year?

2. Are you worried you might have a fall? Not at all A little

Somewhat Very

3. Do you limit activities now because of fall-related concerns? Never Occasionally

Sometimes Often If client has NOT fallen in the past year, skip questions 4 & 5 below.

4. Where have you fallen?

Getting in & out of bed Bathroom

Outside the home Kitchen

Between the bed & the bathroom

Other:

5. Can you say what makes you more likely to fall?

Feeling dizzy/lightheaded Getting up too quickly

Walking in darkness Certain Shoes

Walking on certain surfaces Turns

Stairs Dim Lighting

Other:

Insurance

Long Term Care Coverage? YES NO

Policy #:

Company:

Phone #:

Contact Agent: