Client Intake Form

1
First, let's start with you!Share your name and contact information.
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Area Code
Phone Number
4
Patient Name
First Name
Last Name
5
Age
6
Date of Birth
Date
Month
Day
Year
7
Gender
Male
Female
Other
8
Show some love <3We'd love to see your loved one. Upload a favorite photo here!
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9
Preferred language?
10
Former Military?
YESNO
11
Do they have a pet(s)? If yes, please specify type and how many.
Please Select
Please Select
No
Yes
Please use this field to specify type and number of pets.
12
Do they smoke?
YESNO
13
Do they drive/require car parking?
YESNO
14
Can you share a little about their personality?
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Small
Ok
Ok
15
What does a typical day look like for them?
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Ok
Ok
16
Where do they currently live?
Home (Self or with spouse)
Family Member (Adult child or other)
Assisted Living
Other
17
Reason for moving / seeking senior care facility?
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Ok
Ok
18
Estimated or Desired Move Date
Date
Month
Day
Year
19
Preferred region for placement?Can be city/town or facility if known
20
What amenities in a care facility are most important to you and your loved one?
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Ok
Ok
21
Room Type
Single (Private Room)
Shared
No preference
22
How will they be paying for care?
Savings/Retirement
Long-Term Care Insurance
Medicaid (MediCal)
Family
Other
23
Have you discussed a budget?If yes, please share a range that you'd like to stay within.
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Ok
Ok
24
Height / Weight
Feet (ft)
Inches (in)
Weight
25
Activities of Daily Living
Please Select
Please Select
Can walk on their own
Requires walker/cane
Requires wheelchair
Unable to ambulate
Ambulation
Please Select
Please Select
No
Yes
Yes - multiple times
Have they fallen before?
Please Select
Please Select
Normal hearing
Has or wears hearing aides
Hearing
Please Select
Please Select
Normal vision
Glasses or contacts
Partial blindness
Legally blind
Vision
Please Select
Please Select
Can bath on their own
Needs assistance with bathing
Bathing
Please Select
Please Select
Can dress on their own
Needs assistance with getting dressed
Dressing
Please Select
Please Select
Can eat on their own
Needs assistance with eating
Eating
Please Select
Please Select
Can use the toilet on their own
Needs assistance with using the toilet
Toileting
26
Is your loved one on hospice?
YESNO
27
Do they require awake night time staff?If yes, please explain.
Please Select
Please Select
No
Yes
If yes, please explain. If no, you may skip and click on "Next" below.
28
Do they have a dementia diagnosis?If yes, please explain
29
Do they have a psychiatric diagnosis?If yes, please explain
30
Do they wander or display exit seeking behavior?
YESNO
31
Do they have diabetes or require insulin?
YESNO
32
Do they have incontinence?
YESNO
33
Do they require wound care?
YESNO
34
Do they require medication management?If yes, please list medications and dose
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Small
Ok
Ok
35
Do they require medical management?If yes, please list all current medical conditions requiring regular care
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Ok
Ok
36
Do they require a special diet? If yes, please explain
37
Are there any other conditions, details or fun facts you'd like to share about your loved one?
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Ok
Should be Empty: