Health Assessment

Client Assessment Form
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Age*
Gender*

MaleFemaleTransgender
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Your Previous Address*
Have you ever lived in shared housing before?*

YesNo
If yes, when and where?*
Current Living Situation*

ShelterLiving on the streetLiving in your carStaying with othersTransitional housingHospitalRehabJail ReleasePrison ReleaseOther
Reason for wanting placement with Home Sweet Home Housing Solutions*
What is your total monthly income amount?*
Do you receive SSI?*

YesNo
Do you receive SSDI?*

YesNo
Do you receive VA benefits?*

YesNo
Do you receive Railroad benefits?*

YesNo
Are you employed?*

YesNo
If yes, where do you work, what is your job title, and how long have you been employed?*
Do you have a valid ID?*

YesNo
Do you have a social security card?*

YesNo
Do you have a birth certificate?*

YesNo
Do you have an insurance card?*

YesNo
Do you receive food stamps?*

YesNo
Do you have a debit card?*

YesNo
Do you have a Representative Payee?*

YesNo
Do you receive any other retired or disability benefits?*

YesNo
If yes, please list other benefits:*
Have you ever been diagnosed with a mental health condition?*

YesNo
If yes, please specify:*
Are you currently experiencing any of the following? (Check all that apply)*

DepressionAnxietyStressMood SwingsNone of the aboveOther
Do you have any of the following chronic illnesses or health conditions?*

Heart DiseaseStrokeCancerDiabetesHypertension (High Blood Pressure)Kidney DiseaseDialysisHIV / AIDSBlindnessAmputeeNone of the aboveOther
Do you have any other health concerns not listed above?*

YesNo
If yes, please explain:*
Substance Use History (If Any):*

AlcoholDrugsNeither
Are You Currently Sober?*

YesNo
If yes, for how long?*
If no, what is your drug(s) of choice and when did you last use?*
Do you have any allergies? (e.g., food, medication, environmental)*

YesNo
If yes, please specify:*
List of daily medications:*
Do you refuse to take your medication at times?:*

YesNo
If yes, please explain medication refusal:*
Do you need assistance with any of the following below?*

No assistance requiredBathingDressingGroomingEatingWalkingTaking your medicationToileting
Do you require grab bars for the shower?*

YesNo
Do you require a shower chair?*

YesNo
Do you use any of the adaptive equipment below?*

IndependentCaneWalkerRollatorWheelchairOther
Do you have incontinence issues?*

NoYes, urine onlyYes, bowel onlyYes, urine and bowel
Do you require a special diet?*

YesNo
If yes, please explain:*
Are you able to prepare your own meals?*

YesNo
Any other accommodations needed?*

YesNo
If yes, please specify:*
Do you have any other information you would like to share?*

YesNo
If yes, please specify:*
What is your preferred move-in-date?*

MonthDayYear
Date
Consent

By entering my name below, I acknowledge the information provided is accurate to the best of my knowledge and I consent to its use for the purpose of my application. If accepted into this program, we can use your health information for purposes of health care circumstances, including emergencies. This form is encrypted and the health information that you provide is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA).
Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
Should be Empty:

Client Assessment Form