Client assessment form-what info you should have on your forms

1. Personal Information:

   – What is your full name and date of birth?

   – What is your current address?

   – Contact information (phone number, emergency contacts)?

2. Medical History:

   – Do you have any medical conditions or diagnoses?

   – Are you currently taking any medications? If so, please list them.

   – Have you had any recent surgeries or hospitalizations?

   – Do you have any allergies?

3. Mobility and Activities of Daily Living (ADLs):

   – Can you walk independently, or do you use mobility aids like a walker or wheelchair?

   – Do you need assistance with bathing, dressing, grooming, or toileting?

   – Can you prepare meals for yourself, or do you require assistance with cooking and eating?

4. Home Environment:

   – Describe your living situation (e.g., alone, with family, in a nursing home).

   – Are there any specific safety concerns or modifications needed in your home?

5. Care Preferences:

   – What type of care services are you seeking (e.g., personal care, companionship, medical care)?

   – Do you have any specific cultural or dietary preferences?

6. Caregiver Preferences:

   – Do you have any preferences regarding the gender or qualifications of your caregiver?

   – Are there any personality traits or qualities you value in a caregiver?

7. Schedule and Routine:

   – What days and hours do you need care assistance?

   – Do you have any preferred routines or schedules for meals, medications, and activities?

8. Financial and Insurance Information:

   – Do you have insurance coverage for homecare services?

   – Are there any financial arrangements or payment options you’d like to discuss?

9. Emergency Preparedness:

   – Do you have a plan in place for medical emergencies or unexpected situations?

   – Are there any specific medical directives or advance care plans you’d like to share?

10. Goals and Expectations:

    – What are your primary goals and expectations for homecare services?

    – Is there anything else you’d like to discuss or share about your needs or preferences?

Your assessment form will help you confirm 1 if this client is a fit for your agency. It will also help you when it’s time to provide staffing for the client.