Client Intake Form

Client Intake Form

Standard intake form for new home health aide clients to collect essential personal, health, home, care, insurance, referral, consent, and signature information.
Client & Primary Contact Information
Client Last Name
Client First Name
Middle Initial
Date of Birth

MonthDayYear
Date
Social Security Number
Height
Weight
Recent significant weight loss?
Approximate amount of weight lost
Primary Contact Name

First NameMiddle NameLast Name
Relationship to Client
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Living Situation & Home Environment
Type of Home
If Other, please specify
Floor
Number of Rooms
Elevator in Building?
Does the client live alone?
List all individuals living in the home
Who is available to assist with caregiving?
Recent Hospitalization / Medical History
Has the client been hospitalized recently?
Hospital Name
Hospital Address
Dates of Hospitalization From

MonthDayYear
Date
Dates of Hospitalization To

MonthDayYear
Date
Reason / Diagnoses
Hospital Contact Person
Hospital Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Functional & Sensory Status
Is the client usually alert and able to answer questions?
Can the client direct the home health aide about their care?
If no, who will direct the aide?
Speech impairment
Vision impairment
Hearing impairment
Difficulty using hands or arms
Difficulty using legs or feet
Uses assistive devices

Other
Breathing problems
Heart or circulation problems
How do these conditions affect daily activities?
Mental & Emotional Status
Oriented to place and time?
Memory problems?
Signs of anxiety/agitation?
Signs of depression/sadness?
History of wandering/getting lost?
Unsafe behaviors?
Can the client express their needs?
Sleep problems?
Other mental/emotional concerns?
Medication Management
Able to take medications independently?
If help is needed, who assists with medications?
Can caregiver be taught to administer medications?
How are medications organized?
Special instructions or concerns
Bowel & Bladder / Elimination
Bowel continence
Bladder continence
Toileting equipment / supplies used
Special toileting needs
Personal Care & Daily Living Needs
Grooming
Dressing
Bathing
Washing up
Toileting
Urinal/bedpan/commode
Catheter care
Feeding self
Meal preparation
Reheating meals
Laundry
Shopping
Housecleaning
Special diet or food restrictions
Mobility & Transfers
Walking inside
Walking outside
Getting up from chair
Getting out of bed
Transferring to toilet/commode/wheelchair/shower
Any recent falls?
If yes, describe
Medical Treatments & Special Care Needs
Current Special Care Needs

Other
Other Special Treatments
Infectious Disease / TB History
History of Tuberculosis?
Currently on tuberculosis treatment or prophylaxis?
Date / result of last tuberculosis test
Insurance & Financial / Coverage Information
Home care insurance benefits
Benefits exhausted
Eligible for Medicaid
Applied for Medicaid
If not applied or not eligible, please explain
Other Services & Referral Source
Other agency/vendor providing services?
If yes, agency name(s) and services
Referral source

Other
If referred by someone, provide name/contact
Consent & Signature
Name of Person Completing Form

First NameLast Name
Relationship to Client
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
Signature
Should be Empty:

Client Intake Form

Client & Primary Contact Information

Living Situation & Home Environment

Recent Hospitalization / Medical History

Functional & Sensory Status

Mental & Emotional Status

Medication Management

Bowel & Bladder / Elimination

Personal Care & Daily Living Needs

Mobility & Transfers

Medical Treatments & Special Care Needs

Infectious Disease / TB History

Insurance & Financial / Coverage Information

Other Services & Referral Source

Consent & Signature