Home Health Certification And Plan Of Care

Bee Helpful Home Care Questionnaire
Todays Date

DayMonthYear
Date
Client Information
Name*

First NameLast Name
Nick Name
Phone Number (of person needing care)*
Please enter a valid phone number.
Date of birth*

MonthDayYear
Date
Email
example@example.com
Address *
Communication with family required? Any restrictions with communication with others?
How can the caregiver enter the home?

Knock and someone will answerThe caregiver lets themselves in
Do you have any allergies?*
Diagnosis that make home care necessary*
For example: arthritis, surgery, low vision, dementia
If yes please explain
Do you have any contagious conditions?*
If yes please explain
Are there any safety precautions we should know about?*
For example: "keep wheel chair next to recliner"
Will the caregiver need any specific equipment?*
Do you have a medical alert?
Do you have a DNR?*
If yes, we will need a copy
Functional limitations*

DenturesLow visionBowel/BladderOxygenHearingFall riskEnduranceDo not leave unattendedSpeechNoneOther
Please explain the other functional limitations
Select mental status*

No concernsAnxietyForgetfulDepressedDisorientedAgitatedDementia/AlzheimersOther
Please explain other
Mobility*

Walk without assistanceCaneNo RestrictionsWalkerPT ExercisesWheelchairOther
Please explain the other
Help Needed
Meals

BreakfastWater reminderLunchSnacksDinner
Please explain meal needs or dietary restrictions
Housekeeping

KitchenBathroomChangeLinenLaundryVacuumShower stand byMedication reminderTrash outTrash bin at curbOther
Please explain other housekeeping needs
Companionship

ErrandsBathroomAccompany on walksPet careVacuumTransportationOther
Please explain errands and other companionship needs
Personal Care

ToiletingShowerShampoo at sinkDressingPrescription managementOther
Please explain other personal care needs
Others living in home?
Communication with family or others?
Emergency contact name*

First NameLast Name
Emergency contact phone number*
Please enter a valid phone number.
Emergency contact relation
If referred, who referred you?
Are there firearms in the household?*

Yesno
Are there any pets in the home?*
Are there smokers in the household?*
Email adress you want the invoice sent to*
example@example.com
Should be Empty:

Bee Helpful Home Care Questionnaire