Home Wellness Visit Note
Complete a concierge-style assessment during the visit to generate a report for family members afterward.
Client Information
Client Full Name
*
First Name
Last Name
Client ID#
*
Form Recipient Email
example@example.com
Date of Visit
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Care Advisor Name
*
First Name
Last Name
Care Advisors Email
example@example.com
Living Environment & Safety
General Condition of Home
*
Clean and well-maintained
Some clutter or maintenance needed
Needs significant attention
Other
Safety Concerns Observed
*
Trip hazards
Poor lighting
Unsecured rugs
Bathroom safety issues
No concerns
Other
Kitchen
Refrigerator
*
Well Stocked
Spoiled Food
Expired Food
Ice Machine
*
Working
Not Working
Mold/mildew/unsafe
Stovetop
*
Working
Not Working but sanitary
Not working and unsanitary
Oven
*
Working
Not Working but sanitary
Not working and unsanitary
Trash in the Kitchen
*
Taken out
Not being taken out to the dumpster
Rodents
*
Yes (any evidence at all)
No
Insects
*
Yes (any evidence at all)
No
Lighting
*
All bulbs working
Bulbs are out and how many
General Condition of the Kitchen
*
Clean and well-maintained
Some clutter or maintenance needed
Needs significant attention
Other
HVAC
A/C
*
Working correctly during appropriate months
Not working when needed
Heater
*
Working correctly during appropriate months
Not working when needed
Flooring
Carpet
*
Maintained
Not maintained and why (ex. animal droppings, tears)
Flooring
*
Maintained
Not maintained and why (ex. animal droppings, tears)
Rugs
*
Maintained
Not maintained and why (ex. animal droppings, tears)
Main Bathroom
Toilets
*
Working
Not working and why
Toilets (Sanitary)
*
Sanitary
Not sanitary
Fall Hazards in Toilet Area
*
No Fall Hazards
Fall Hazards
Shower/Tub
*
Working
Not working and why
Shower/Tub (Sanitary)
*
Sanitary
Not sanitary
Fall Hazards in Shower/Tub Area
*
No Fall Hazards
Fall Hazards
Lighting
*
All bulbs working
Bulbs are out and how many
General Condition of the Bathroom
*
Clean and well-maintained
Some clutter or maintenance needed
Needs significant attention
Other
Mobility & Fall Risk
Mobility Level
*
Independent
Uses assistive device
Needs assistance
Bed-bound
Other
Any recent falls?
*
No
Yes, within last 30 days
Yes, more than 30 days ago
Nutrition & Hydration
Appetite and Meal Routine
*
Eats regular meals
Irregular meals
Needs meal support
Hydration Status
*
Adequate
Needs reminders
At risk of dehydration
Attending Spiritual House of Worship
Do they attend a spiritual house of worship?
*
Yes
No
If yes, are the attending their spirtual house of worship as regularly as they wish?
Yes, attending on a regular basis with little to no difficulty
Attending of a less do to moderate or serious difficulty
They are receiving spiritual care at home or virtually
They are wanting help in meeting their spiritual or religious needs
Medication & Wellness
Client verbally verified medication is well maintained
*
They did verify medication is well maintained
They noted medication is not well maintained
General Wellness Observations
*
Social, Cognitive & Emotional Well-being
Social Engagement
*
Active and engaged
Somewhat engaged
Isolated
Cognitive Status
*
Alert and oriented
Mild memory concerns
Significant memory issues
Mood & Emotional State
*
Positive
Some concerns
Significant concerns
Recommendations & Next Steps
Next Step Notes for Client/Family
*
Summary / Additional Notes
*
Care Advisor
*
I have completed the full walk through and the information I have provided is accurate.
Care Recipient
*
My care advisor visited my home today and they walked me through my care plan and their recommendations.
Submit Visit Note
Submit Visit Note
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