Client Application

Address *

E-mail
Phone Number *

Area Code Phone Number
Emergency contact *

First Name Last Name
Phone number *

Area Code Phone Number
Insurance
Doctor Name *

First Name Last Name
Doctor Number

Area Code Phone Number
Care/Case Manager Name

First Name Last Name
Care/ Case Manager Number

Area Code Phone Number
If hours are already approved, how many? (Only for case managers)
Number of hours
Clients informations - Health questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q 1 *

	Yes	No
Do the client have any Mental Health issues our Agency should know about?
Do the client use cain, walker, or wheel chair?
Do the client lose balance because of dizziness or do you ever lose consciousness?
Do the client have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Do the client have a condition that prevents him/her from signing documents?
Do you know of any other reason why you should not do physical activity?

Please read the questions carefully and answer each one honestly:

Do you (the client) have difficulty with the following?

Par-Q 2 *

	Without any difficulty	With some difficulty	With much difficulty	Unable to do
Dressing yourself (includes: tying shoelaces and doing buttons)
Getting in and out of bed?
Lifting a cup or glass to mouth?
Bending down to pick up items from the floor?
Getting in and out of car or bus?
Washing and drying entire body.

I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials *

Clear
Any Additional information that we should know about?
Comments
Client informations - Signature
Signature *

Clear
Date *

Mois Jour Année
at
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