CLIENT ASSESSMENT FORM
CLIENT RE-ASSESSMENT FORM
Interview Date: ___________
Start of Care Date: ____________
Client Name: __________________________ Phone: ________________ Type: ______________
E-Mail Address: ___________________________________________________________________
Client Address: ___________________________________________________________________
Date of Birth: ___________ Height: _______ Weight: _______ Marital Status: __________________
Emergency Contact: ___________________________ Relation: ____________________________
Phone: ___________________ Cell: _____________________ Work: ________________________
E-Mail Address: ___________________________________________________________________
Physician: ____________________________ Phone: ________________ Fax: ________________
Home Health: __________________________ Phone: ________________ Fax: ________________
Hospice: ______________________________ Phone: ________________ Fax: ________________
Principle Diagnosis________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------Mental Status:
Oriented
Forgetful
Disoriented
Agitated
Comatose
Depressed
Lethargic
Dementia
Alzheimer’s
GEM Status: _______________________
--------------------------------------------------------------------------------------------------------------------------------------Prognosis:
Poor
Good
Fair
Excellent
Guarded
--------------------------------------------------------------------------------------------------------------------------------------Functional Limitations:
Amputation
Incontinence
Contracture
Paralysis
Dyspnea
Endurance
Ambulation
Hearing
Speech
Swallowing
Legally Blind
Other: _____________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------Activities Permitted:
No Restrictions
100% Bed Rest
Bed Rest BRP
Up as Tolerated
Wheelchair
Walker
Crutches
Cane
Transfer to….
Exercise
Partial Weight Bearing
Smoking
Other: ___________________________________________________
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CLIENT ASSESSMENT FORM
CLIENT RE-ASSESSMENT FORM
DME and Supplies:_________________________________________________________________
Safety Measures:__________________________________________________________________
Nutritional Requirements:____________________________________________________________
Allergies:_________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------Activities of Daily Living:
Mobility:
Asst. w/Ambulation
Asst. w/Transfers
Bed/Chair Only
ROM Exercises
Toileting:
Bathroom
Bedpan
Urinal
Commode
Incontinence:
Occasional
Full
Bowel
Bladder
Briefs
Selfcare
Bathing:
Complete
Partial
Tub
Shower
Sponge
Sink
Vision Loss:
R. Eye
L. Eye
Peripheral Only
Hearing:
Hard of Hearing
Wears Hearing Aid(s)
Glasses
Def
Diet:
Normal
Diabetic
Feeding Assistance
Low Sodium
Liquid Only
Assist Meal Prep
Feeding Instructions: ____________________________________
Skin Care:
Moisturizer
Powder
Other: _____________________________________
Hair Care:
Wash & Dry
Wash & Set
Comb & Brush
Oral Care:
Brush & Floss
Denture Care
Dressing:
Dresses Self
Help Select Clothes
Weight:
Weigh Client
Frequency:
Shopping:
Drives Self
Assist with Dressing
C/G may take out
CG to drive Clients Car
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CLIENT ASSESSMENT FORM
CLIENT RE-ASSESSMENT FORM
Call before taking out
Accompany on Taxi/Bus
Client has Vehicle Ins.
Recreation:
Outdoor Recreation
Guidelines: ___________________________________________
Housekeeping:
None
Normal
Light
Laundry
Special Notes:
-------------------------------------------------------------------------------------------------------------------------------------Social Notes:
Pets:
Pet care
Dog(s)
Cat(s)
Other: ________________________________
Favorite Activity: __________________________________________________________________
Personal Management: _____________________________________________________________
Friends & Visitors: _________________________________________________________________
Activities / Habits: _________________________________________________________________
Eating / Talking: ___________________________________________________________________
Smoking:
Client
Family
Indoors
Med Managed
Med Reminders
Outdoors
Medications:
Food: ___________________________________________________________________________
Sleep: ___________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------Office Information:
Level of Care:
CC
PC
PP
Service Rate:
Per Hour $ ________
Per Day $ _________
Payment Options:
PVT
CC
ACH
MCD
VA
Revised April 7, 2022
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CLIENT ASSESSMENT FORM
CLIENT RE-ASSESSMENT FORM
Schedule
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Start
End
Total Hours Per Week: ______________________
Family Contact Information
Name
Relation
Phone
E-mail
Notes:
Revised April 7, 2022
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CLIENT ASSESSMENT FORM
CLIENT RE-ASSESSMENT FORM
______________________________________________________
Client’s Signature
________________
Date
______________________________________________________
Client Rep. Signature
________________
Date
______________________________________________________
Assessor’s Signature
________________
Date
List of Individuals Participating in the development of the service Plan:
Name
Relationship to Client
Revised April 7, 2022
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