Client Assessment Form Step 1 of 17 5% Person providing the informationName* First Last Client InformationClient Name First Last Address* Street Address Address Line 2 City Phone*Additional PhoneCurrent Living Conditions Brief HistoryHow long at current residence?Where from?Marital status?Children? Yes No Details about childrenPlease describe more details about the children such as: "2 boys, 2 girls"Grand children? Yes No Details about grand childrenPlease describe more details about the grand children such as: "2 boys, 2 girls"Previous occupation(s)?History of disabilitiesWhen did things become challenging? Preferred ActivitiesFavourite activities currently able to doFavourite activities currently unable to doHobbiesMember of clubs and organisationsSpecify meeting timesRegular appointments / social engagementsSpecifyMember of churchSpecify meeting timesEntertainment preferenceseg: symphony, theatre, movies etcOther social activitiesFamily in area?Visit how often?PetsTypes (dog / cat / fish) and namesRequired care for pets?Veterinarian’s name and phone number General Observations of Social BehaviourSocial Behaviour Outgoing and Active Withdrawn Comments about social behaviour Shopping and ErrandsWho is currently doing the shopping?How often?Other routine errands? AmbulationAmbulation selectionWalks without assistanceUses cane or walkerUses wheelchairNeeds lifting from bed / chair DrivingAble to drive? Yes No Has own car for caregiver to use? Yes No MealsSpecial dietary concerns?Typically eats Breakfast Lunch Dinner Snacks Breakfast timePlease specify roughly what time breakfast is usually eatenLunch timePlease specify roughly what time lunch is usually eatenDinner timePlease specify roughly what time dinner is usually eatenSnack timesPlease specify roughly what times snacks are usually eatenWho cooks?Other food providers?Favourite foods? Dressing & BathingAbility to dress Able to dress self Needs assistance Ability to bathe No assistance necessary Family will bathe Bathing assistance Monitoring only Bathing compliancy Compliant Non-compliant LaundryWho currently does laundry?How often?HousekeepingWho currently does housekeeping?How often?Areas in need of cleaning?Sleep HabitsArisesBedtimeDescribe nocturnal wakeningDescribe daytime nappingGreatest FearsGreatest Fears Medical ConditionsDiagnosed illnesses, diseases, or conditions:Prescription MedicationsPrescription MedicineOver The Counter MedicationsOver The Counter MedicationsSpecial Medication Instructions PharmacyLocationPhone contactGPGP Name First Last GP Address Street Address Address Line 2 City GP PhoneGP Nurse Name First Last EyeglassesEye DoctorPhone ContactDentalDentistPhone ContactDentures Yes No Needs work? Incontinence Bladder Bowel Able to self-identify and / or self-manage changing needs Incontinence products in useAny of the below suffered by client Dementia Alzheimer’s Wandering Dementia symtomsAlzheimer’s symtomsWandering symtomsWander Guard and Life-Line Device Usage Uses Wander Guard Uses Life-Line Device Wander Guard companyLife-Line Device CompanyOther symptoms suffered Substance abuse Other Substance abuse descriptionOther sympton description Legal DocumentationIs there any of the following in place? Living Will Durable Medical Power of Attorney DNR Chemical Compression None Legal Documentation Instructions Emergency InstructionsCall HospiceHospice PhoneAsk forHospice contact nameHospice instructions DNR Chemical Compression None Hospice document locationEmergency ContactIn the event of an emergency, the CareGiver will call 000 and notify the home office. Which family members should we notify?Emergency Contact Name First Last Emergency Contact RelationshipEg: Partner, Spouse, Son, Daughter...Emergency Contact Daytime PhoneEmergency Contact Evening PhoneEmergency Contact Mobile PhoneIf there is another emergency contact please enter their details hereEmergency Contact 2 Name First Last Emergency Contact 2 RelationshipEg: Partner, Spouse, Son, Daughter...Emergency Contact 2 Daytime PhoneEmergency Contact 2 Evening PhoneEmergency Contact 2 Mobile Phone Call Religious LeaderCall Religious Leader? Yes No Religious Leader Name First Last ReligionReligious Leader Daytime PhoneReligious Leader Evening PhoneReligious Leader Mobile PhoneDeterminationIs the client appropriate for home care? Yes No Determination Reasons
