Caregiver Training Questionnaire

Caregiver Training Consultation Questionnaire
Full Name of Caregiver

First NameLast Name
Gender

MaleFemale
Date of Birth

MonthDayYear
Age
years
Height
cm
Name of the person for whom you provide care.
KG
Date of birth of the person for whom you provide care.
Please select the area(s) of Caregiver Training needed.

Injury Prevention/Body Mechanics TrainingTransfers and Functional Mobility TrainingSafety EduationMedication ManagementOther
Do you follow a regular working schedule, do you work days, afternoon or nights?
How often are you with the patient?

DailyA few times a weekI live with the person for whom I provide careOther
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
If you have any injuries, please list them.
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Do you suffer from diabetes, asthma, high or low blood pressure?

YesNo
Please list:
Are you a current cigarette smoker?

YesNo
Please rate your readiness for change.

12345678910
What is your goal with your training?
Why?
How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
At what times during the day would you prefer to train?

MorningMid-DayAfternoonEvening
1.) CANCELLATIONS

Cancellations should be made at least 48 hours in advance of a scheduled session. Sessions cancelled less than 48 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session shall be 1 hour in length. Sessions will not be extended (unless time is available) due to the lateness of the client or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE TO THE ABOVE TERMS & CONDITIONS!

YesNo
Should be Empty:

Caregiver Training Consultation Questionnaire