Client-Patient Information Form
Please complete this form to ensure that we have the correct basic information in file. Contact us at getcare@caringhearthomecare.com or 1(424) 201-1057.
Client Information
Please provide the client's (you) information below.
Relationship to patient:
*
Family/Relative
Guardian
Power of Attorney
Friend
Self
CHHC Office
Client Name
*
First Name
Last Name
Client Phone Number
*
-
Area Code
Phone Number
Client Email
*
example@example.com
Client/Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Information
Information of individual receiving the care.
Patient Name
*
First Name
Last Name
Patient Phone Number
*
-
Area Code
Phone Number
Patient Email
*
example@example.com
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Start Date
-
Month
-
Day
Year
Date
Preferred place to receive care:
*
Home
Assisted Living
Nursing Home
ADDRESS FOR CARE SERVICES (Please skip if it is the same as stated above for patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Weight
Height
Medical Background
Medical Condition(s)
*
Medications taken/currently taking:
*
(If more than three, please provide a list)
Range of mobility:
*
Independent Walking
Partially Ambulatory
Non-Ambulatory
With Assistance
Using Walker/Cane
Other
Can the patient stand?
on his/her own
with assistance only
using a walker/cane
bedbound
Is lifting required?
Partial/lift assist
Total lift
Can patient help while being lifted?
Yes
No
Is the patient continent?
Yes
No
Cognitive Ability
Alert
Oriented
Dementia / Alzheimer's
Beginning
Moderate
Advanced
Sundowner
Not applicable
Is the patient receptive to care?
Yes, likes to be cared for by a non family member
No, resists care and sometimes combative
DNR?
*
How did you hear about us?
*
Services
Caregiver Preference:
*
Male
Female
Age Range:
*
Mid 20s
Mid 30s
Mid 40s
Doesn't matter
Transportation:
*
Driving caregiver
Non-driving caregiver
Ethnicity:
Special Instructions:
Please let us know if you have any specific requests!
Type of care needed:
*
Companion Care
Personal Care Attendant
Health/Safety Supervision
Hospice
Post Op/Rehab care
Live-in Care
Hourly Care
Quick Care
Services Needed:
*
Home safety supervision
Personal hygiene maintenance/grooming
Medication reminder
Light housekeeping
Bathing/Showering/Toilet assistance
Transportation to medical/dental/personal appointments
Monitoring vital signs (i.e. blood pressure, blood sugar)
Grocery/Shopping errands
Meal preparation/Light cooking
Laundry/Linen change
Financial Means
Mode of payment:
*
Out of pocket/Private payments
Another person will pay services
Long-term care/Private care insurance
Other
Additional Notes/Information:
Emergency Contact Information
(1) Primary Contact:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to patient:
*
Wife
Husband
Daughter
Son
Family/Relative
Guardian
Power of Attorney
Friend
(2) Primary Contact:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to patient:
*
Wife
Husband
Daughter
Son
Family/Relative
Guardian
Power of Attorney
Friend
Medical Emergency Detail:
(if more than one, please provide a list)
(1) Doctor/Specialists:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
(2) Doctor/Specialists:
First Name
Last Name
Phone Number
-
Area Code
Phone Number
(Optional) Please upload any files such as meal prep instructions, medications, etc.
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By my signature, I affirm and certify that all the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief.
*
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