Visiting Angels Assessment

Client Assessment

Providing information to provide excellent care!

Visiting Angels
236 Adley Way
Greenville, SC 29607
p. (864)284-6370
f. (864)284-6379

Re: Assessment

Dear Sir or Madam,

Thank you for taking the time to provide Visiting Angels with the enclosed information. Caregiver selection is a delicate and painstaking process, and your attention to detail will allow us to more closely align and select a caregiver as we will have a clear definition of your history, present day needs and specific expectations.

We look forward to a wonderful experience of being your care provider and again, thank you for the very precious gift of your trust. If we can be of any help at any time, it would be our pleasure to do so. Please know that we welcome your call at ANY time as we are available to serve you 24 hours a day.

Warmest Regards,

Daniel Radulescu, CSA, VAGAL
Director | Certified Senior Advisor | Vulnerable Adult Guardian ad Litem

Visiting Angels "Senior Homecare by Angels!"
Phone: 864-244-6300 | Fax: 888-284-3080
Email: Daniel@SCVisitingAngels.com

Client Assessment

Please complete as much information as possible
Assessment Mode and Attendees
How is this assessment being conducted?*
Who is conducting the assessment?*
Assessment Completed By:

First NameLast Name
Visiting Angels Representative

First NameLast Name

Who is in attendance and/or providing client information?*

	Full Name	Relationship	Authority
Person 1
Person 2
Person 3
Person 4
Person 5

Demographics
Full Name of person being cared for*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number
ONLY NEEDED WITH LONG TERM CARE INSURANCE
Is there a second person needing care?

YesNo
Full Name of SECOND person being cared for*

First NameLast Name
SECOND person's Date of Birth*

MonthDayYear
SECOND person's Social Security Number
Address where care will be provided*

Street Address

CityState

Zip Code
Cell Phone Number
Home Phone Number
Email Address
example@example.com

Other Important Contacts

	Name	Address	Phone	Email	Relationship
1
2
3
4
5

Medical Information
{CR1FullName}: Medical Information
Diagnosis - Primary / Secondary

Alzheimer'sBed BoundArthritisCancerCOPDCHF - Congestive Heart FailureDementiaDiabetesEmotional IrregularitiesFalling - Fall RiskHearing LossIncontinence CareParkinson's DiseaseStrokeVision ProblemsOther
Additional diagnosis notes

Providers on the care team (primary care physicians, neurologists, cardiologists, etc.)

	Name	Specialty	Practice	Location
Provider 1
Provider 2
Provider 3
Provider 4
Provider 5

Medication List
Medication Notes
Picture of Medication List

Cancelof
Picture of Medication List 2

Cancelof
Picture of Medication List 3

Cancelof
Picture of Medication List 4

Cancelof

Are you currently experiencing any pain or discomfort?

	Body Part	Cause	Pain Level (1-5)	Notes
1
2
3
4
5

Have you had any recent changes in condition (past 90 days)?
Have there been any hospitalizations in the past 5 years?
List any allergies or sensitivities
Cognitive Status
Emotional Status
Equipment Currently Used For Care

NoneWheelchairRolatorCaneGlassesReading GlassesBed Side CommodeDenturesPartialsMechanical LiftGate BeltShower ChairRaised CommodeWheelchair RampRoll In ShowerWalkerHospital BedHearing AidsGrab BarsOther
Equipment Notes
{CR2FullName}: Medical Information
Diagnosis - Primary / Secondary

Alzheimer'sBed BoundArthritisCancerCOPDCHF - Congestive Heart FailureDementiaDiabetesEmotional IrregularitiesFalling - Fall RiskHearing LossIncontinence CareParkinson's DiseaseStrokeVision ProblemsOther

Medication List*
Medication Notes

Have you had any recent changes in condition (past 90 days)?
Have there been any hospitalizations in the past 5 years?
List any allergies or sensitivities
Cognitive Status
Emotional Status
Equipment Currently Used For Care

NoneWheelchairRolatorCaneGlassesReading GlassesBed Side CommodeDenturesPartialsMechanical LiftGate BeltShower ChairRaised CommodeWheelchair RampRoll In ShowerWalkerHospital BedHearing AidsGrab BarsOther
Personal Care Needs
{CR1FullName}: Personal Care Needs
Daily Routine
Activities of Daily Living (ADL) Needs

NoneWashing BackBrushing TeethBrushing HairBathing - TubWashing HairShaving - ElectricHelp in/out showerBathing - SpongeDrying OffShaving - RazorFall RiskBathing - ShowerDressingFiling NailsStand By OnlyBathing - BedDenture CareSocks and ShoesOther
Activities of Daily Living (ADL) Notes - Other Details
Is transportation required?

No, transportation is NOT required.Yes, in the clients car (no additional charge).Yes, in the caregivers car ($0.60/mile charge).Unsure at this time.
Transportation Notes: Car type, Upcoming or Standing Appointments, Instructions, etc.
{CR2FullName}: Personal Care Needs
Daily Routine*
Activities of Daily Living (ADL) Needs

NoneWashing BackBrushing TeethBrushing HairBathing - TubWashing HairShaving - ElectricHelp in/out showerBathing - SpongeDrying OffShaving - RazorFall RiskBathing - ShowerDressingFiling NailsStand By OnlyBathing - BedDenture CareSocks and ShoesOther
Activities of Daily Living (ADL) Notes - Other Details
Is transportation required?

No, transportation is NOT required.Yes, in the clients car (no additional charge).Yes, in the caregivers car ($0.60/mile charge).Unsure at this time.
Dietary Needs
{CR1FullName}: Dietary Needs
Are there any dietary restrictions, preferences or concerns?

What do your typical meals and snacks consist of

	Time of Day	Like to Drink	Like to Eat
Breakfast
Snack
Lunch
Snack
Supper
Snack

{CR2FullName}: Dietary Needs
Are there any dietary restrictions, preferences or concerns?

Home Environment

May we help with any light housekeeping?

	Day	Time	Supplies	Notes
Floors - Sweep
Floors - Mop
Floors - Vacuum
Kitchen - Dishes
Kitchen - Wipe Counters
Kitchen - Put Away Groceries
Kitchen - Check for Expired Food
Laundry - Wash / Dry Clothes
Laundry - Change Bed Linens
Laundry - Fold and Put Away
Bedroom - Tidy Up
General - Dust
General - Take out Trash
General - Check Mail
Bathroom - Clean Toilet
Bathroom - Clean Sink
Bathroom - Clean Shower
Other 1
Other 2
Other 3

Additional Light Housekeeping Notes

Are there any pets in the home?

	Type	Name	Size	Friendly	Needs
Pet 1
Pet 2
Pet 3
Pet 4

Social Interactions
Providing social interaction and engagement can provide connectivity and meaning for seniors who are now than ever feeling isolated and alone. There are several way that this can be accomplished by blending in person and virtual/remote caregiving. Would any of these be beneficial to enrich the life of the individual that we are caring for?
There are a LOT of ways that we can encourage interaction. Would any of these be helpful?

CompanionshipVideo Chat with friends/familySocial OutingsEngagement (Puzzles, crafts, etc.)Phone Calls with friends/familySocial outings (church, gatherings, etc.)Medication Reminder CallsDaily status/check in callsSetup Alexa, Facebook Portal, Smart HomeOther
Engagement / Interaction Notes
Can you please let us know a little bit about the history and interests of the person we are caring for?
Emergency Actions
{CR1FullName}: Emergency Actions

Who would we contact in the event of an emergency

	Name	Phone	Relationship	POA	Contact 1st	Contact 2nd	Notes
1
2
3

In an emergency, do you want CPR to be performed by emergency medical personnel?*

DO NOT perform CPR, I wish to die a natural death (We Request posting your DNR).Allow CPR to be performed by emergency personnel.Unsure at this time - all lifesaving measures will be taken unless otherwise specified.
{CR2FullName}: Emergency Actions

In an emergency, do you want CPR to be performed by emergency medical personnel?*

DO NOT perform CPR, I wish to die a natural death (We Request posting your DNR).Allow CPR to be performed by emergency personnel.Unsure at this time - all lifesaving measures will be taken unless otherwise specified.
Moving Forward
What are the MOST IMPORTANT things to be mindful of in providing care?

Did you have a schedule in mind of care during the week?

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Week 1
Week 2
Week 3
Week 4

When did you want to have care start?

MonthDayYear
Date
Hour MinutesAM/PM Option
To move forward with care, we would need to complete the Authorization for care. Are you comfortable completing the Authorization now?*

YesNo
Funnel Stage
Date

MonthDayYear
Date
Should be Empty:

Client Assessment

Client Assessment