Client Questionnaire
This form is to be completed by new clients seeking personal assistance services for themselves or their loved ones.
Today's Date
*
-
Month
-
Day
Year
Date
Today's Time
*
Hour Minutes
AM
PM
AM/PM Option
Person Needing Service
*
First Name
Last Name
Address where service is to be provided
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Mobile Number
*
Email
*
example@example.com
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Responsible Party (Power of Attorney if applicable)
First Name
Last Name
Why are you looking for home care assistance?
*
Where did you hear about us?
*
PROMO CODE
Please put N/A if you don't have one.
ABOUT THE CLIENT
Diagnosis - please select all that apply
Alzheimer's Disease
Amyotrophic Lateral Sclerosis (ALS)
Arrhythmia of the Heart
Arthritis
Atrial Fibrillation
Autism
Bedsores (pressure ulcers)
Bipolar Disorder (Manic-depressive illness)
Cancer
Cataracts
Cholesterol
Chronic Kidney Failure
COPD, or Chronic Obstructive Pulmonary Disease
Diabetes
Fibromyalgia
Glaucoma
Heart Disease
Hepatitis
HIV/AIDS
Hypertension (High Blood Pressure)
Hyperthyroidism (overactive thyroid)
Hypothyroidism (underactive thyroid)
Irritable Bowel Syndrome (IBS)
Incontinence, Urinary
Inflammatory Bowel Disease (IBD)
Kidney Failure, Chronic
Leukemia
Liver Failure, Acute
Liver Spots (Age Spots)
Lupus
Lymphoma, Hodgkin's (Hodgkin's disease)
Lymphoma, Non-Hodgkin's
Macular Degeneration, Dry
Melanoma, Skin Cancer
Multiple Sclerosis (MS)
Obstructive Sleep Apnea
Osteoarthritis
Osteoporosis
Pancreatic Cancer
Parkinson's Disease
Periodontitis
Pneumonia
Post-traumatic stress disorder (PTSD)
Rheumatoid Arthritis
Staph Infections
Stroke
Thrush, Oral
Transient Ischemic Attack (TIA)
Tuberculosis (TB)
Ulcerative Colitis
Vascular Dementia
Vertigo
Wrinkles
N/A
Recent Hospitalizations
*
if not applicable, put NA
Weight Status
*
Increase
Static
Decrease
Other
Recent weight changes
*
if not applicable, put NA
Gender
*
Male
Female
Not specified
Need for Palliative Care
*
Yes
No
Dental Care
*
if not applicable, put NA
Vision
if not applicable, put NA
Mental Health Status
if not applicable, put NA
Anticipated Discharge Date (If this does not apply, please skip)
-
Month
-
Day
Year
Date
Discharge Instructions
Current Care Setting
Primary Doctor
Emergency Contact
*
First Name
Last Name
Emergency Contact (Mobile Number)
*
Relationship
*
LIVING HABITS
Smoking
*
Yes
No
Other
Alcohol Consumption
*
Yes
No
Other
Current Diet
*
if not applicable, put NA
Allergies Food & Others
*
if not applicable, put NA
Eating Habits / Appetite
*
Good
Fair
Poor
Other
COMMUNICATION
Primary Language
*
Speaks/Understands English
*
Yes
No
Can Communicate Needs
*
Yes
No
Non-verbal
*
Yes
No
Understanding
*
Unimpaired
Understands Keywords Only
Understanding Unknown
Understands Simple Phrases Only
Unresponsive
FUNCTIONAL STATUS
Assistive Devices
*
Hearing Aids (L/R)
Glasses
Dentures
Cane
Walker
Wheelchair
Crutches
Psychosocial
*
Alert
Oriented
Confused
Forgetful
Wanders
Functional Limitations
*
Hard of hearing
Legally blind
Amputee
Paralyzed
Does Not Apply
REFERRAL INFORMATION
Contact Name
First Name
Last Name
Source
Phone Number
Follow-up Requested
Advanced Directive
Yes
No
Other
ACTIVITIES OF DAILY LIVING
Bathing
*
Independent Bathtub or Shower
Independent with Mechanical Aids
Requires Minor Assistance or Supervision:
Getting In/Out of Tub/Shower
Turning Taps On/Off
Washing Back
Requires Continued Assistance
Resists Assistance
Dressing
*
Independent
Supervision or Needs some occasional assist
Periodic or Daily Assist Needed
Grooming & Hygiene
*
Independent
Reminder, Motivation &/or Direction
Assistance with Some Things
Requires Total Assistance
Resists Assistance
Eating
*
Independent
Independent with Special Provision for Disability
Intermittent Assist With:
Cutting Up/Pureeing Food
Must Be Fed
Resists Feeding
Bladder Control
*
Totally Continent
Needs Routine Toileting or Reminder
Incontinent occasionally
Incontinent daily
Bowel Control
*
Total Control
Needs Routine Toileting or Reminder
No Bowel Control Due to Identifiable Factors
Loses Bowel Control occasionally
Loses Bowel Control daily
Does Not Apply
Use of Restroom
*
Raised Toilet Seat or Commode
Difficulty with Buttons, Zippers
Needs Help with Aids (e.g. Catheter, Condom Drainage, etc.)
Does Not Apply
Exercise/Movement
*
Exercises Regularly
Type/Time/Distance
Recent Changes to Routine
Exercise Alone
Exercises With Attendant
At Home
At Facility
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Food Prep
*
Independent
Able if Ingredients Supplied
Can Make/Buy Meals Diet is Inadequate
Physically/Mentally Unable to Prepare Food
Chooses Not to Prepare Food
Housekeeping
*
Independent
Generally Independent but Needs Help with Heavier Tasks
Can Perform Only Light Tasks Adequately
Performs Light Tasks but Not Adequately
Needs Regular Help and/or Supervision
No Opportunity to Do Housework/Chooses Not to Do Housework
Shopping
*
Independent
Independent for Small Items Only
Can Shop if Accompanied
Physically/Mentally Unable to Shop
No Opportunity to Shop/Chooses Not to Shop
Transportation
*
Uses Private Vehicle
Uses Taxi/Bus
Independent
Must be Accompanied
Must be Driven
Physically or Mentally Unable to Travel
Needs Ambulance for Transporting
Telephone
*
Independent
Can Dial Well Known Numbers
Answers Telephone Only
Physically or Mentally Unable
No Opportunity to Use Telephone/Chooses Not to
SOCIAL & FINANCIAL PROFILE
Housing
*
House
Apartment
Condo
Mobile Home
Facility
Living Companions
*
Alone
With Spouse/Partner
With Adult Child
With Child(ren)
With Other Adult Male
With Other Adult Female
Principal Helper:
Ethnicity
*
Religion
*
Actively Practicing?
*
Yes
No
Financial Management
*
Self
Spouse
Family
Friend
Trustee
Power of Attorney
Select Services
Please choose all services that you will need our agency to complete for the person seeking service.
Personal Care Services
Total Bed Bath
Assist Bed Bath
Assist Shower
Assist Tub
Sponge Bath
Shampoo
Conditioner
Comb/brush hair
Clean Dentures
Brush teeth
Dress
Shave (safety razor)
Nail Care
Clean Client areas
Medications (remind & assist with self-administered meds)
Wellness Check
Oxygen safety
Weight
Blood Pressure checks as needed
Toilet/Elimination Tasks
Urinal
Commode
Bedpan
Toilet
Assist to bathroom
Incontinence brief
Incontinence care
Empty Urinary bag
Nutrition Tasks
Prepare Meal
Prepare Meal (help)
Total feed
Assist with feeding
Fluids
Mobility Tasks
Bedrest
Assist to transfer
Assist to ambulate
Wheelchair
Walker
Exercise Assist
Exercise assists the range of motion
Precautions
Infection control: Handwashing, Standard Precautions
Choking (if the client is prone while eating)
Bleeding (bedsores)
Fall prevention
Support Services
Walk Dog
Cane
Crutches
Change bed linens
Make Client bed
Laundry
Shopping
Light Cleaning
Errands
Pull Trash
Transport
Deep Clean
Special Instructions/Services Not Listed
Additional Comments:
Service Frequency - Please select all days and the times you are seeking the particular service category from the services you selected above.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Personal Care Services
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Toilet/Elimination Tasks
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Special Instructions
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Nutrition Tasks
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Mobility Tasks
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Precautions
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Support Services
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Morning
Day
Evening
Overnight
24 Hours
Additional Comments for Service Frequency:
Form of Payment:
*
Please Select
Cryptocurrency
Quickbooks Online(credit/debit card)
Zelle
Do you plan to file a Long-Term Insurance Claim?
*
Yes
No
When do you need services to begin?
*
-
Month
-
Day
Year
Date
Best time for a Senior Shield Associate to call you:
Client/Responsible Party's Signature
Name
*
First Name
Last Name
Submit
Should be Empty: