Harmony Home Services New Client Intake Form

Client Intake Form

Detailed home health client intake form for patients and their families.
Client Information
Client Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Gender
Primary Language
Marital Status
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Apartment / Entry Details
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party / POA
Responsible Party / POA Name

First NameMiddle NameLast Name
Responsible Party Relationship
Responsible Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Email
example@example.com
Emergency Contacts
Primary Emergency Contact Name
Primary Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact Name
Secondary Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical Providers & Preferred Facilities
Primary Care Physician Name
Primary Care Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Specialist / Clinic Name
Specialist / Clinic Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Hospital
Pharmacy
Health & Medical Information
Primary Diagnosis / Relevant Conditions
Allergies
Current Medications
Home Safety & Access
Safety Concerns

Other
Code / Entry Instructions
Alarm Details
Mobility Equipment Used
Transfer Assistance Needed
Diet / Texture Restrictions
Fluid Restrictions
Bathroom Setup / Shower Access Notes
Sleep Routine Notes
Pet Information
Pet Name(s)
Pet Type / Breed
Pet Approximate Size / Weight
Pet Age
Pet Feeding Schedule / Food Location
Pet Water Routine
Pet Walking / Outside Routine
Leash / Waste Supply Location
Pet Behavior Notes / Triggers / Bite History / Escape Risk / Handling Limits
Veterinarian / Clinic & Phone
Pet Medications or Special Care Instructions
Authorized Pet Services

Other
Daily Routines & Preferences
Morning routine / wake time
Preferred meals / snacks
Bathing / grooming preferences
Conversation, hobbies, TV, music, faith, or social preferences
Triggers, dislikes, or behaviors the caregiver should know
Authorizations & Agreements
Agreement to Contact Listed Contacts
Understanding of Service Scope
Notice of Changes
Signature
Client / Responsible Party Signature
Signature Date

MonthDayYear
Date
Should be Empty:

Client Intake Form

Client Information

Responsible Party / POA

Emergency Contacts

Medical Providers & Preferred Facilities

Health & Medical Information

Home Safety & Access

Pet Information

Daily Routines & Preferences

Authorizations & Agreements

Signature