Client's Personal Information:
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information (Name, Relationship, Phone)
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Medical Information:
Primary Diagnosis/Condition(s)
Medications currently being taken (name, dosage, frequency)
Allergies
Dietary restrictions
Physician's contact information
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Physical Abilities and Mobility:
Level of assistance required for transferring and ambulating
independent
supervision
full assistance
Use of any mobility aids (walker, cane, wheelchair, etc.)
Fall risk assessment
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Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs):
Level of assistance required for each ADL and IADL, including bathing, dressing, grooming, toileting, feeding, meal preparation, medication management, housekeeping, laundry, and transportation
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Cognitive and Emotional Status:
Level of cognitive function (memory, problem-solving, decision-making)
Presence of any cognitive impairment or dementia
Emotional well-being and mood
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Communication:
Ability to communicate effectively (verbal, written, or other methods)
Language preferences
Hearing and vision abilities
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Preferred Schedule and Frequency of Care:
Preferred days and times for caregiver visits
Desired frequency of care (daily, weekly, etc.)
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Goals and Expectations for Care:
Client's and family's goals and expectations for the care provided
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Should be Empty: