Bee Helpful Home Care Questionnaire
Todays Date
-
Day
-
Month
Year
Date
Client Information
Name
*
First Name
Last Name
Nick Name
Phone Number (of person needing care)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth
*
-
Month
-
Day
Year
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 answer
The caregiver lets themselves in
Do you have any allergies?
*
Please Select
Yes
No
Diagnosis that make home care necessary
*
For example: arthritis, surgery, low vision, dementia
If yes please explain
Do you have any contagious conditions?
*
Please Select
Yes
No
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?
Please Select
Yes
No
Do you have a DNR?
*
Please Select
Yes
No
If yes, we will need a copy
Functional limitations
*
Dentures
Low vision
Bowel/Bladder
Oxygen
Hearing
Fall risk
Endurance
Do not leave unattended
Speech
None
Other
Please explain the other functional limitations
Select mental status
*
No concerns
Anxiety
Forgetful
Depressed
Disoriented
Agitated
Dementia/Alzheimers
Other
Please explain other
Mobility
*
Walk without assistance
Cane
No Restrictions
Walker
PT Exercises
Wheelchair
Other
Please explain the other
Help Needed
Meals
Breakfast
Water reminder
Lunch
Snacks
Dinner
Please explain meal needs or dietary restrictions
Housekeeping
Kitchen
Bathroom
ChangeLinen
Laundry
Vacuum
Shower stand by
Medication reminder
Trash out
Trash bin at curb
Other
Please explain other housekeeping needs
Companionship
Errands
Bathroom
Accompany on walks
Pet care
Vacuum
Transportation
Other
Please explain errands and other companionship needs
Personal Care
Toileting
Shower
Shampoo at sink
Dressing
Prescription management
Other
Please explain other personal care needs
Others living in home?
Communication with family or others?
Emergency contact name
*
First Name
Last Name
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency contact relation
If referred, who referred you?
Are there firearms in the household?
*
Yes
no
Are there any pets in the home?
*
Are there smokers in the household?
*
Email adress you want the invoice sent to
*
example@example.com
Submit
Should be Empty: