Client Application

Welcome sheet - Client informations
Full name *

First Name Last Name
Birth Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
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

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 Hour Minutes AM/PM Option
Should be Empty: