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About
- Our Caregivers
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Locations
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Blog
Contact

Client Intake Form

Patient Intake Form (#3)

Newsletter

Client Information

Client's Name

Last

Client's Phone Number

Marital Status

Living Situation

Client's Address

City, State

Zip Code

Client's Email

Date of Birth

Client's Age

Gender:

Female

Male

Does the client live with anyone?

Yes

No

Who?

Does the Client have Advance Directives?

Is the Client a DNR or Full Code?

Emergency Contact Information

Emergency Contact 1

Address

Relationship to Client

City, State

Phone Number

Zip Code

Email

POA Medical

POA Financial

Billing Contact

N/A

Do you want access to the Client's Online Portal?

Yes

No

Are we able to discuss client information with this person?

Yes

No

Emergency Contact 2

Emergency Contact

Address

Relationship to Client

City, State

Phone Number

Zip Code

Email

Title

POA Medical

POA Financial

Billing Contact

N/A

Do you want access to the Client's Online Portal?

Yes

No

Are we able to discuss client information with this person?

Yes

No

Emergency Contact 3

Emergency Contact

Address

Relationship to Client

City

Phone Number

Zip Code

Email

Title

POA Medical

POA Financial

Billing Contact

N/A

Do you want access to the Client's Online Portal?

Yes

No

Are we able to discuss client information with this person?

Yes

No

Insurance Information

Will the Client be using Insurance?

Yes

No

Primary Insurance

Secondary Insurance

Policy Number

Policy Number

Group Number

Group Number

Care Providers & Medical Services

Primary Care Doctor:

Phone Number

Will we need to provide Transportation to visits?

Yes

No

Address

City, State Zip

Does the Client have specialist we will need to take them too?

Yes

No

Specialist Name

Specialist Name

Address

Address

Phone Number

Phone Number

Preferred Pharmacy

Pharmacy Phone Number

Is the Client on Hospice

Yes

No

Does the Client use Home Health?

Yes

No

Home Health Agency Name

Phone Number

Hospice Provider Name

Hospice Number

Medical History:

Mark all that Apply:

Anemia

Bleeding / Clotting Problem

Heart Attack

Stents

Congestive Heart Failure

A – Fibrillation

Heart Murmur

Heart Valve problems

Stroke

TIA

Seizure or epilepsy

Dementia

Parkinson’s

COPD

Asthma

Tuberculosis

Diverticulosis

Ulcer

Reflux

Hernia

Gallstones

Cancer

Kidney Stones

Liver Disease

Osteoporosis

Skin Conditions

Stomach Problems

Thyroid Problems

Anxiety

Depression

Shingles

Sleep Apnea

Renal Failure

UTI Low Sodium

High Blood Pressure

Diabetes

Incontinence of Urine

Incontinence of Stoll

Sleep Issues

Is the Client on Blood Thinners?

Yes

No

Does the Client track their blood pressure?

Yes

No

When?

Does the Client track their blood sugar's?

Yes

No

When?

Does use insulin?

Yes

No

How Often

Does the Client have any know Allergies?

Yes

No

Unknown

Please list all known allergies.

What reaction does the client experience with this allergy?

Check All that Client Currently Has:

Glasses

Contacts

Dentures

Hearing aids

Cane

Walker

Wheelchair

Lift Chair

Gait Belt

Grab Bars

Bed Rails

Shower Chair

Raised Toilet Seat

Bedside Commode

Blood Pressure Monitor

Pulse Oximeter

Sugar Monitor

Oxygen

Emergency Response System

Urinal

Baby Monitor

Hospital Bed

Catheter

Check all the Apply:

Communication Issues

Hearing Issues

Leaving on the Stove

Limited use of Hands

Poor Balance

Swallowing Issues

Wandering

Verbal Aggression

Limited use of Arms

Fall Risk

Blind

Misplacing Items

Physical Aggression

Poor Appetite

Vision Issues

Daily Living Functions

Use the scale below to assess the client’s ability, considering consistency, safety, and need for assistance.

Bathing

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Dressing

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Grooming

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Toileting

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Transferring to and from

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Standing from Sitting

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Walking

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Climbing Stairs

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Shopping

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Cooking

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Housework

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Laundry

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Using Small Appliances

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Driving

Independent

Limited Assistance

Extensive Assistance

Unable to Perform

Care Plan

How did you hear about us?

How many days per week do you need service?

How many hours a day?

When are you wanting services to start?

How long do you anticipate needing service?

Check all services that you would like provided

Vacuum / Mop Floors

Dust

Iron

Empty Trash to exterior Can

Wash / Dry / Fold Laundry

Wash / Dry / Put away dishes

Make Beds

Client Transportation (errands)

Clean Bathrooms

Assistance with Dressing

Assistance with Dentures

Assistance with Feeding

Assistance with Exercise

Toileting

Companionship

Pull trash can to road

Straighten up Clutter

Change Bedding / Linens

Medication Reminders

Assistance with Brushing Teeth

Assistance with socks/shoes

Meal preparation

Transfers

File Fingernails

Check Mail

Transportation (Doctor's Appointments)

Caregiver Preferences

What is your preference in caregiver?

Are there any areas/items that you would like the caregiver to leave alone?

Is there anything else we need to know to help make the shift successful?

What are your main goals for having in home care?

Providing home care services for aging loved ones that are no longer able to be as independent as they once were. With heavenly hands, Affordable Assist Private Care will provide you peace of mind.

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931-200-3058
affordableassistinhome@gmail.com
236 Miller Ave. Crossville, Tn 38555
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