Client Questionnaire

Client Questionnaire

This form is to be completed by new clients seeking personal assistance services for themselves or their loved ones.
Today's Date*

MonthDayYear
Date
Today's Time*

Hour Minutes

AM/PM Option
Person Needing Service*

First NameLast Name
Address where service is to be provided*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Mobile Number*
Email*
example@example.com
Client's Date of Birth*

MonthDayYear
Date
Responsible Party (Power of Attorney if applicable)

First NameLast 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 DiseaseAmyotrophic Lateral Sclerosis (ALS)Arrhythmia of the HeartArthritisAtrial FibrillationAutismBedsores (pressure ulcers)Bipolar Disorder (Manic-depressive illness)CancerCataractsCholesterolChronic Kidney FailureCOPD, or Chronic Obstructive Pulmonary DiseaseDiabetesFibromyalgiaGlaucomaHeart DiseaseHepatitisHIV/AIDSHypertension (High Blood Pressure)Hyperthyroidism (overactive thyroid)Hypothyroidism (underactive thyroid)Irritable Bowel Syndrome (IBS)Incontinence, UrinaryInflammatory Bowel Disease (IBD)Kidney Failure, ChronicLeukemiaLiver Failure, AcuteLiver Spots (Age Spots)LupusLymphoma, Hodgkin's (Hodgkin's disease)Lymphoma, Non-Hodgkin'sMacular Degeneration, DryMelanoma, Skin CancerMultiple Sclerosis (MS)Obstructive Sleep ApneaOsteoarthritisOsteoporosisPancreatic CancerParkinson's DiseasePeriodontitisPneumoniaPost-traumatic stress disorder (PTSD)Rheumatoid ArthritisStaph InfectionsStrokeThrush, OralTransient Ischemic Attack (TIA)Tuberculosis (TB)Ulcerative ColitisVascular DementiaVertigoWrinklesN/A
Recent Hospitalizations*
if not applicable, put NA
Weight Status*

IncreaseStaticDecreaseOther
Recent weight changes*
if not applicable, put NA
Gender*

MaleFemaleNot specified
Need for Palliative Care*

YesNo
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)

MonthDayYear
Date
Discharge Instructions
Current Care Setting
Primary Doctor
Emergency Contact*

First NameLast Name
Emergency Contact (Mobile Number)*
Relationship*
LIVING HABITS
Smoking*

YesNoOther
Alcohol Consumption*

YesNoOther
Current Diet*
if not applicable, put NA
Allergies Food & Others*
if not applicable, put NA
Eating Habits / Appetite*

GoodFairPoorOther
COMMUNICATION
Primary Language*
Speaks/Understands English*

YesNo
Can Communicate Needs*

YesNo
Non-verbal*

YesNo
Understanding*

UnimpairedUnderstands Keywords OnlyUnderstanding UnknownUnderstands Simple Phrases OnlyUnresponsive
FUNCTIONAL STATUS
Assistive Devices*

Hearing Aids (L/R)GlassesDenturesCaneWalkerWheelchairCrutches
Psychosocial*

AlertOrientedConfusedForgetfulWanders
Functional Limitations*

Hard of hearingLegally blindAmputeeParalyzedDoes Not Apply
REFERRAL INFORMATION
Contact Name

First NameLast Name
Source
Phone Number
Follow-up Requested
Advanced Directive

YesNoOther
ACTIVITIES OF DAILY LIVING
Bathing*

Independent Bathtub or ShowerIndependent with Mechanical AidsRequires Minor Assistance or Supervision:Getting In/Out of Tub/ShowerTurning Taps On/OffWashing BackRequires Continued AssistanceResists Assistance
Dressing*

IndependentSupervision or Needs some occasional assistPeriodic or Daily Assist Needed
Grooming & Hygiene*

IndependentReminder, Motivation &/or DirectionAssistance with Some ThingsRequires Total AssistanceResists Assistance
Eating*

IndependentIndependent with Special Provision for DisabilityIntermittent Assist With:Cutting Up/Pureeing FoodMust Be FedResists Feeding
Bladder Control*

Totally ContinentNeeds Routine Toileting or ReminderIncontinent occasionallyIncontinent daily
Bowel Control*

Total ControlNeeds Routine Toileting or ReminderNo Bowel Control Due to Identifiable FactorsLoses Bowel Control occasionallyLoses Bowel Control dailyDoes Not Apply
Use of Restroom*

Raised Toilet Seat or CommodeDifficulty with Buttons, ZippersNeeds Help with Aids (e.g. Catheter, Condom Drainage, etc.)Does Not Apply
Exercise/Movement*

Exercises RegularlyType/Time/DistanceRecent Changes to RoutineExercise AloneExercises With AttendantAt HomeAt Facility
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Food Prep*

IndependentAble if Ingredients SuppliedCan Make/Buy Meals Diet is InadequatePhysically/Mentally Unable to Prepare FoodChooses Not to Prepare Food
Housekeeping*

IndependentGenerally Independent but Needs Help with Heavier TasksCan Perform Only Light Tasks AdequatelyPerforms Light Tasks but Not AdequatelyNeeds Regular Help and/or SupervisionNo Opportunity to Do Housework/Chooses Not to Do Housework
Shopping*

IndependentIndependent for Small Items OnlyCan Shop if AccompaniedPhysically/Mentally Unable to ShopNo Opportunity to Shop/Chooses Not to Shop
Transportation*

Uses Private VehicleUses Taxi/BusIndependentMust be AccompaniedMust be DrivenPhysically or Mentally Unable to TravelNeeds Ambulance for Transporting
Telephone*

IndependentCan Dial Well Known NumbersAnswers Telephone OnlyPhysically or Mentally UnableNo Opportunity to Use Telephone/Chooses Not to
SOCIAL & FINANCIAL PROFILE
Housing*

HouseApartmentCondoMobile HomeFacility
Living Companions*

AloneWith Spouse/PartnerWith Adult ChildWith Child(ren)With Other Adult MaleWith Other Adult FemalePrincipal Helper:
Ethnicity*
Religion*
Actively Practicing?*

YesNo
Financial Management*

SelfSpouseFamilyFriendTrusteePower 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 BathAssist Bed BathAssist ShowerAssist TubSponge BathShampooConditionerComb/brush hairClean DenturesBrush teethDressShave (safety razor)Nail CareClean Client areasMedications (remind & assist with self-administered meds)Wellness CheckOxygen safetyWeightBlood Pressure checks as needed
Toilet/Elimination Tasks

UrinalCommodeBedpanToiletAssist to bathroomIncontinence briefIncontinence careEmpty Urinary bag
Nutrition Tasks

Prepare MealPrepare Meal (help)Total feedAssist with feedingFluids
Mobility Tasks

BedrestAssist to transferAssist to ambulateWheelchairWalkerExercise AssistExercise assists the range of motion
Precautions

Infection control: Handwashing, Standard PrecautionsChoking (if the client is prone while eating)Bleeding (bedsores)Fall prevention
Support Services

Walk DogCaneCrutchesChange bed linensMake Client bedLaundryShoppingLight CleaningErrandsPull TrashTransportDeep 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
Toilet/Elimination Tasks
Special Instructions
Nutrition Tasks
Mobility Tasks
Precautions
Support Services

Additional Comments for Service Frequency:
Form of Payment:*
Do you plan to file a Long-Term Insurance Claim?*

YesNo
When do you need services to begin? *

MonthDayYear
Date
Best time for a Senior Shield Associate to call you:
Name*

First NameLast Name
Client/Responsible Party's Signature

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Client Questionnaire

ABOUT THE CLIENT

LIVING HABITS

COMMUNICATION

FUNCTIONAL STATUS

REFERRAL INFORMATION

ACTIVITIES OF DAILY LIVING

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

SOCIAL & FINANCIAL PROFILE

Select Services