• Client 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

    Client Assessment

    Please complete as much information as possible

  • Assessment Mode and Attendees

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

  • Demographics

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is there a second person needing care?
  • SECOND person's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Other Important Contacts
    Rows

  • Medical Information

  • {CR1FullName}: Medical Information
  • Diagnosis - Primary / Secondary
  • Providers on the care team (primary care physicians, neurologists, cardiologists, etc.)
    Rows
  • Medication List
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  • Are you currently experiencing any pain or discomfort?
    Rows
  • Equipment Currently Used For Care
  • {CR2FullName}: Medical Information
  • Diagnosis - Primary / Secondary
  • Providers on the care team (primary care physicians, neurologists, cardiologists, etc.)
    Rows
  • Medication List*
  • Are you currently experiencing any pain or discomfort?
    Rows
  • Equipment Currently Used For Care

  • Personal Care Needs

  • {CR1FullName}: Personal Care Needs
  • Daily Routine
  • Activities of Daily Living (ADL) Needs
  • Is transportation required?
  • {CR2FullName}: Personal Care Needs
  • Daily Routine*
  • Activities of Daily Living (ADL) Needs
  • Is transportation required?
  • Dietary Needs
  • {CR1FullName}: Dietary Needs
  • What do your typical meals and snacks consist of
    Rows
  • {CR2FullName}: Dietary Needs
  • What do your typical meals and snacks consist of
    Rows
  • Home Environment
  • May we help with any light housekeeping?
    Rows
  • Are there any pets in the home?
    Rows
  • 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?
  • Emergency Actions
  • {CR1FullName}: Emergency Actions
  • Who would we contact in the event of an emergency
    Rows
  • In an emergency, do you want CPR to be performed by emergency medical personnel?*
  • {CR2FullName}: Emergency Actions
  • Who would we contact in the event of an emergency
    Rows
  • In an emergency, do you want CPR to be performed by emergency medical personnel?*
  • Moving Forward
  • Did you have a schedule in mind of care during the week?
    Rows
  • When did you want to have care start?
     - -
    2 digit month, 2 digit day, 4 digit year
  • To move forward with care, we would need to complete the Authorization for care. Are you comfortable completing the Authorization now?*
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: