Client Application

Welcome sheet - Client informations
Full name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Phone Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Insurance
Doctor Name*

First NameLast Name
Doctor Number

Area CodePhone Number
Care/Case Manager Name

First NameLast Name
Care/ Case Manager Number

Area CodePhone 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*

Rows	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*

Rows	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*

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

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Date*

MoisJourAnnéeHourMinutesAM/PM Option
Should be Empty: