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Client Eligibility: Our services are available to seniors who require assistance with activities of daily living (ADLs), individuals with disabilities or chronic illnesses, patients recovering from surgery or hospitalization, and family caregivers in need of respite support.

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Name: *

First

Last

Date of Birth: *

Email: *

Phone Numbers: *

Age: *

Gender: *

Address: *

Emergency Contact Phone: *

Relationship:

Mobility *

• Independent
• Required Assistance
• Bedbound

in Emergency Special

Assistive Device Used *

• Cane
• Walker
• Wheelchair
• Other

Other

Hearing *

• Normal
• Impaired
• Deaf

Speech *

• Normal
• Impaired
• Non-Verbal

Allergies *

• None
• Yes (Specify)

If yes…

Special Diet *

• None
• Yes (Specify)

If yes…

Medication Assistance Needed *

• Yes
• No

Daily Living Activities (ADLs) Assistance Needed *

• Bathing
• Dressing
• Grooming
• Toileting
• Eating
• Transferring (Bed/Chair)
• Walking
• Medication Reminder
• Light Housekeeping
• Meal Preparation
• Shopping/Errands
• Transportation
• Companionship

Cognitive & Emotional Conmdition *

• Fully Aware
• Sometimes Confused
• Disoriented

Memory Issue *

• None
• Mild
• Moderate
• Severe

Mood Behavior *

• Stable
• Anxious
• Depressed
• Agitated

History of Dementia/Alzheimer *

• Yes
• No

Behavioral Concerns (if any)

Living Arragement *

• Alone
• With Family
• Assisted Living

Home Environment Safety *

• Clutter
• Poor Lighting
• No Grab Bars

Emergency Plan in Place *

• Yes
• No

Pets at Home *

• Yes
• No

Service Plan & Goals *

• Daily
• Weekly
• Other

Specific Goals for Care:

Additional Notes

Assessment Conducted by *

First

Last

Client/Guardian Signature *

Submit Assessment