UnaCare HCA In-take Form

Start Date of Services *

Month Day Year
Start Time

Hour Minutes

AM/PM Option
End Time

Hour Minutes

AM/PM Option
End Date of Services *

Month Day Year
Phone number *
E-mail *
Preferred contact method *

Phone Email
Name of Care Client *
Address , City and Zip *
Date Of Birth *

Month Day Year
Gender *

Male Female Other
Any Pets?
Allergies? *
Used by Client (Select all that apply) *

Walker Cane BSC Oxygen
Precautions (Select all that apply) *

Seizure Precautions Fall Prone High Risk Meds Constant Monitoring Aspiration Anxiety Other
Nutrition and Dietary ( Select all that apply)

Prepare Food Serve Food Breakfast Lunch Dinner Snacks Other
Food Instructions Menu for client and Restricted Foods
Services Needed *

Bathing Continence Care Dressing Transferring to from bed Grooming Mobility Eating Light House Keeping Meal Preparation Laundry Necessity Shopping Other
House Hold Services (Select all that apply) *

Change Linen Make Bed Laundry Iron Dust Vacuum Clean Kitchen Wash Dishes Empty Trash Check food in refrigerator Other
How many times has Client fallen in the past year? *
Any Additional Notes: For Caregiver
Should be Empty: