New Client Home Care readiness form
Thank you for considering KalCare to partner with you in caring for your loved one.We understand that choosing home care is an important decision. Our Home Care Readiness Packet allows us to learn about your loved one's needs before your Complimentary Home Care Readiness Visit so we can provide personalized recommendations and spend our time focused on your family's goals. Estimated Completion Time 10–15 minutes
Client Information
Title
Please Select
Mr.
Mrs.
Ms.
Mx.
Dr.
Prof.
Other
First Name
*
Last Name
*
Goes By
Gender
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Birth Date
*
-
Month
-
Day
Year
Date
Address Line 1
*
Address Line 2
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
Zip Code
*
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Desired Service Start Date
*
-
Month
-
Day
Year
Date
Advance Directives / Legal
Advance Directive
*
Yes
No
Advance Directive Notes
Advance Directive File Upload
Upload File
Drag and drop files here
Choose a file
Upload any supporting Advance Directive document.
Cancel
of
Do Not Resuscitate (DNR)
*
Yes
No
DNR Notes
DNR File Upload
Upload File
Drag and drop files here
Choose a file
Upload any supporting DNR document.
Cancel
of
Durable Power of Attorney
*
Yes
No
POA Full Name and Telephone Number
Durable Power of Attorney File Upload
Upload File
Drag and drop files here
Choose a file
Upload any supporting Power of Attorney document.
Cancel
of
Health & Medical History
Client health problems and health history
*
Medical equipment
Client medications
Service Needs & Preferences
Service Days Needed
*
Daily
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred Service Start Time
*
Early Morning
Morning
Late Morning
Afternoon
Evening
24/7
Description of Desired Daily Routine
Care Provider Preferences
Physician Information
Primary Care Physician Name
First Name
Last Name
Primary Care Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Physician Facility Name
Specialty Care Physician #1 Name
First Name
Last Name
Specialty Care Physician #1 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Specialty Care Physician #1 Facility Name
Specialty Care Physician #2 Name
First Name
Last Name
Specialty Care Physician #2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Specialty Care Physician #2 Facility Name
Additional Physician Information
Responsible Parties / Contacts
Responsible Party #1 Name
*
Responsible Party #1 Relationship
*
Responsible Party #1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party #1 Medical Decisions Authorization
*
Yes
No
Responsible Party #1 HIPAA Disclosure Authorization
*
Yes
No
Responsible Party #2 Name
*
Responsible Party #2 Relationship
*
Responsible Party #2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party #2 Medical Decisions Authorization
*
Yes
No
Responsible Party #2 HIPAA Disclosure Authorization
*
Yes
No
Physical Measurements
Height (feet)
*
Height (inches)
*
Weight
*
Health Conditions
Vision Issues
*
Yes
No
Speaking Issues
*
Yes
No
Breathing Issues
*
Yes
No
Heart Issues
*
Yes
No
Blood Pressure Issues
*
Yes
No
Circulation Issues
*
Yes
No
Bed Bound
*
Yes
No
Paralysis
*
Yes
No
Cancer
*
Yes
No
Arthritis
*
Yes
No
Diabetes
*
Yes
No
Dementia
*
Yes
No
Seizures
*
Yes
No
Hearing Loss
*
Yes
No
Tremors
*
Yes
No
Stroke
*
Yes
No
Alzheimer's
*
Yes
No
Wounds
*
Yes
No
Recent Surgery
*
Yes
No
Incontinence
*
Yes
No
Chronic Pain
*
Yes
No
Allergies
*
Yes
No
Fall Risk / Imbalance
*
Yes
No
Parkinson's
*
Yes
No
Supportive Devices / Equipment
Dentures
*
Yes
No
Glasses
*
Yes
No
Hearing Aid
*
Yes
No
Hospital Bed
*
Yes
No
Ramp
*
Yes
No
Transfer Board
*
Yes
No
Mobility Cart
*
Yes
No
Cane
*
Yes
No
Raised Toilet Seat
*
Yes
No
Raised Furniture
*
Yes
No
Bed Rails
*
Yes
No
Hand-held Shower
*
Yes
No
Wheelchair
*
Yes
No
Lift Chair
*
Yes
No
Bedside Commode
*
Yes
No
Oxygen
*
Yes
No
ERS
*
Yes
No
Shower Chair
*
Yes
No
Grab Bars in Bathroom
*
Yes
No
Walker
*
Yes
No
Adult Diapers
*
Yes
No
Mechanical Lift
*
Yes
No
Baby Monitor
*
Yes
No
Other Supportive Devices
*
Yes
No
Description Medical History
Insurance & Payment
Medical Insurance Provider (N/A if not applicable)
*
Medical Insurance Policy Number (N/A if not applicable)
*
Additional Medical Insurance Information (N/A if not applicable)
Insurance & Payment File Upload
Upload File
Drag and drop files here
Choose a file
Upload any supporting insurance or payment documents.
Cancel
of
Home Care Payment Type
*
Private Medical Insurance
Short Term Disability
Long Term Disability
Medicaid Waiver Program
Private Pay
Workers Compensation
Other
Please Upload Physicians Orders, Medication Profile, Medical History Information
Upload File
Drag and drop files here
Choose a file
Upload any supporting medical history documents.
Cancel
of
Signature Section
First Name of Signer
*
Last Name of Signer
*
Relationship of Signer
*
Please Select
Client
Spouse
Parent
Adult Child
Sibling
Legal Guardian
Power of Attorney
Other
Client/POA Signature
*
Submit
Submit
Should be Empty: