Client or their Representative Should Please Complete this form
* - Limited to the direct care of the client ** - Including wound care, NG Tube feeding, IV Fluids, Injections, Tracheostomy care, PEG Tube Feeding etc.
Kindly tick or write as required.
History of chronic illness (Please check all that apply):
(1 POINT) Bathes self completely or needs help in bathing only a single part of the such as the back, genital area or disabled extremity.
(0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower, Requires total bathing
(1 POINT) get clothes from closet and drawers and puts on cloth and outer garments complete with fasteners. May have help trying shoes
(0 POINTS) Needs help with dressing self or needs to be completely dressed.
(1 POINT) goes to toilet, gets on and off, arranges clothes, cleans genital area without help.
(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or
(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transferred aids are acceptable
(0 POINTS) Needs help in moving from bed to chair or requires a complete transfer.
(1 POINT) Exercise complete self-control over urination and defecation.
(0 POINTS) Is partially or totally incontinent of bowel or bladder
(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done
(0 POINTS) needs partial or total help with feeding or requires parenteral feeding.
The above information is true and correct to the best of my knowledge.
I am authorizing Rockgarden Homecare Agency to conduct an in-home assessment and to provide Homecare Services for my ward, named above.