New Client Info. Request Form

New Client Info. Request Form

Information obtained are stored using HIPAA standards.
1 - Personal Info.
Date *

Month Day Year
Date
Client Name *

First Name Last Name
Date of birth *

Month Day Year
Date
Age
Height *
Weight *
Gender *
Pets?
2 - Patient Contact Info.
Address *

Street Address

Street Address Line 2

City State

Zip Code
Client Phone# *
Please enter a valid phone number.
Email *
example@example.com
Patient Lives...? *
If Client lives with Spouse/ Partner/ Others, pls indicate name.
Spouse/ Partner Phone Number#
Please enter a valid phone number.
3 - Brief Medical Info.
DNR (Do Not Resuscitate) Available? *
DNR Code?
Diabetic?
High Blood Pressure?
Primary Medical Condition *
Brief Medical History
4 - Additional Info.
Mental Condition (Please select all that applies)

Sharp Mild Cognitive Impairment Dementia Alzheimer's Disease Drug interaction Stroke Sundowning Hallucination Anxiety Depression Others Prefer not to say
Are there any relevant info we should be aware of with regards to the client’s MENTAL condition/status?
Leave blank if none
Behavioral (Please select all that applies)

Calm Sweet Forgetfulness Agitated Crankiness Combative Aggressive/ Threatening Behavior Risky Behavior Impulsive Behavior Compulsive Behavior Apathy Others Prefer not to say
Are there any relevant info we should be aware of with regards to the client’s BEHAVIORAL condition/status?
Leave blank if none
Physical State (Please select all that applies)

Mobile Needs assistance in walking Needs assistance in getting up/ standing up Fall Risk Weak UPPER body Weak LOWER body Knee Condition Hip Condition Others Prefer not to say
Are there any relevant info we should be aware of with regards to the client’s PHYSICAL condition/status?
Leave blank if none
Equipment(s) used (Please select all that applies)

Walker Cane Wheelchair Electric Wheelchair Hospital Bed Hoyer Lift Stair Lift Comode Seat Riser CPAP Nebulizer Oxygen Others Prefer not to say
Are there any relevant info we should be aware of with regards to the client’s Equipment(s)?
Leave blank if none
Meal Preference (Please select all that applies)

Normal diet Low-Sodium diet Gluten Free Allergies Pureed Thickened Meals on wheels or similar services Others Prefer not to say
Are there any relevant info we should be aware of with regards to the client’s MEAL/ DIET/ EATING HABITS?
Leave blank if none
Lifting Requirements (Please select all that applies)

None None to mild Mild to moderate Moderate to heavy Use of Hoyer lift Two person lift Bed Care (Partial) Bed Care (Full) Prefer not to say
Sleep Pattern (Please select all that applies)

Sleeps well Takes Medication to sleep Gets up 2 to 3 times a night Gets up more than 4 times Wanders around Tries to get out of the house/ Tries to "go home" Restless Others Prefer not to say
Shower frequency (Please select all that applies)

Everyday 2 to 3x/ week 4x or more/ week Sponge bath only Others Prefer not to say
Incontinence (Please select all that applies)

Normal Incontinent Uses depends: protection only Uses depends: full time Toileting assistance Others Prefer not to say
5 - Preference
Preferred Caregiver (Please select all that applies)

Female Male No preference
Driving (Please select all that applies)

Driving Non-Driving can be considered No preference
Automobile (Please select all that applies)

Client has a car Care provider has to have a car Family/ Friend can drive Client around UBER/ Lyft Other arrangements No preference
Other Requests
6 - Long Term Care Insurance

We are approved by LTC Insurance companies. If you have a policy, please let us know. We can help you file claims. If none, please move to section 7.
Does the patient have Long Term Care Policy? If none, please skip to section 6.A

Yes No Unsure Prefer not to say
If YES, please indicate LTC company
Policy#
Claim# (if any)
Last 4 digits of SSN
LTC Info/ Instructions
7 - Legal Representation
Legal Representative Name - if something happens to you. *

First Name Last Name
Representative Role (select all that applies) *

Self Power of attorney (POA) Healthcare Directive Conservator Others
Relation *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Legal Representative Phone# *
Please enter a valid phone number.
Legal Representative Email *
example@example.com
In case Patient is unavailable to make payments, Legal Representative will handle all payments. *

Yes No
Other information/ instructions about Legal Representation
Almost done.
I certify the above information are true and correct. *

Client/ Representative Clear
Please review your answers before clicking Submit

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New Client Info. Request Form

1 - Personal Info.

2 - Patient Contact Info.

3 - Brief Medical Info.

4 - Additional Info.

5 - Preference

6 - Long Term Care Insurance

7 - Legal Representation

Almost done.

Please review your answers before clicking Submit