Healthy at Home New Client Form

We appreciate you allowing Healthy at Home the opportunity to support you and your family. In our commitment to provide the best customer service, we ask new clients to complete the following questionnaire so that we can better serve them. Please don't hesitate to call us at 250-762-2233 if you have questions or concerns.

Full Name of New Client*

First NameLast Name

Birthday*

Date

Gender

FemaleMale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Area CodeNumber

Cell Phone*

Area CodeNumber

Emergency Contact: *

Full Name

Relationship to the Client*

Example: Family/Friend/Neighbor

Address:*

Street Address

Email

CityProvince

Postal Code

Email*

example@example.com

Cell Number*

Area CodePhone Number

Home Number

Area CodePhone Number

Support you are looking for:*

How often would you like us to come visit?*

What time of day would be your preference for us to visit?*

How many hours a day would you like us to come visit?*

Brief Medical History:*

Current Diagnosis:*

Height and Weight*

HeightWeight

Do you have a specific date you would like to start?*

Who should we contact to schedule the first visit?*

Name and Phone number

	Important	Not Important	Additional information?
Good listener
Likes to talk
Likes dogs/cats
Enjoys cooking
Non-smoker

New Client Questionnaire

New Client Information

Emergency Contact

Details of the visit