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CLIENT ASSESSMENT FORM

Our revered Client or their Representative should kindly complete this form (it is easy to fill and should require less than 20 minutes)

Please note that all fields marked with an asterisk (*) are required.

Are you receiving services from any other home health or personal care agency?

What does the client need help with?

A or B

A. CAREGIVERS
(Please pick all that apply, but kindly note that service fee is subject to care needs)

General health care; overseeing medication and prescriptions usage, and appointment reminders
Mobility assistance e.g. help with getting in and out of a wheelchair, car or shower
Personal supervision; providing constant companionship and general supervision
Emotional support; being a stable companion in all health related and emotional matters
Dementia Care; orienting or grounding someone with Alzheimer’s disease or dementia, relaying information from a doctor to family members
Assisting with grocery shopping and other errands for your loved one only
Assisting with exercise
Assisting with feeding
Assisting with Hair Care, Nail Care, Oral Hygiene
Assisting with personal care; bathing, grooming and dressing
Assisting with light housekeeping, dishes and light laundry for your loved one only
Basic food preparation; preparing meals for your loved one only
Incontinence care and / or assisting with toileting
Health monitoring; following a care plan and noticing any changes in the individual’s health, recording and reporting any differences

B. REGISTERED NURSES
(Please pick all that apply, but kindly note that service fee is subject to care needs)

Monitoring of vital signs including blood pressure, blood glucose checks and urine tests
Administering oral and skin medications
Administering injections e.g. insulin and IV Fluids
Dressing of wounds
Provide other palliative care as needed to keep the patient comfortable in their homes e.g. administering oxygen therapy
Assisting with oral feeding and exercise
NG Tube feeding
Mobility assistance e.g. help with getting in and out of a wheelchair, car or shower
Assisting with Hair Care, Nail Care, Oral Hygiene
Assisting with personal care; bathing, grooming and dressing
Incontinence care and / or assisting with toileting
Post-surgical management, e.g. surgical wound care, infection monitoring or care of drainage tubes
Provide needed companionship while maintaining close contact with client in order to guarantee a high level of satisfaction
Managing care plans according to their physicians’ specific instructions, overseeing medication and prescriptions usage, and appointment reminders
Monitoring patient recovery and compiling reports for the physician
Providing suggestions for improved healthcare to physicians and family members of the patient
Advising caregivers and family on the ongoing care of the patient
Listening to the concerns of family members and answering their questions
Highly skilled nursing care such as Tracheostomy care, PEG Tube Feeding, care of central venous line (such as peripherally-inserted central catheter)
Other Skilled Nursing Care
Will the client require assistance with any other thing?
History of Urinary Incontinence?
History of Feacal Incontinence?

History of chronic illness (Please tick all that apply):

a. Diabetes
b. Hypertension
c. Hearing impairment
d. Dental problems
e. Stroke/TIA
f. Sleep problems
g. Arthritis
h. Difficulty moving around
i. Blindness or Partial Blindness
j. Congestive heart failure
k. History suggestive of Dementia (e.g. difficulty remembering or retaining information)?
l. History suggestive of Mental illness (e.g. psychosis, depression etc)?
m. Does the client have a cancer or other terminal illness?

PHYSICAL EXAMINATION

INVESTIGATIONS

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.

Signaturekindly use your fingers or a stylus pen to write your signature
(Sign Here)
Clear Signature
Should all correspondence be sent to this person?
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