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Client Information
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Date of Birth
MM slash DD slash YYYY
Gender
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Client Address
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Phone
Weight
Height
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Spouse Name
First
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Household Members? Yes or No
Are there pets in the home?
Emergency Contact Person
Relationship to the client
Emergency Contact Name
First
Last
Emergency Contact Phone Number
Emergency Contact Email
Medical History
Notes
File of Life
Primary Care Doctor Name
Doctor Location (City)
Doctors Phone Number
Pharmacy Name
City of Pharmacy
Hospital of Choice
Facility Name You're In
Facility Name
Facility Room Number
Location
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Discharge Date
Notes
Personal Care
Bed Bathing
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Shower
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Notes
Dressing
Shirt
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Socks
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Pants
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Undergarments
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Notes
Grooming
Comb Hair
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Brush Teeth
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Clean Dentures
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Apply Lotion
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Foot Care: Clean and Trim Nails
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Notes
Toileting
Bed Pan
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Urinal
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Commode
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Raised Toilet Seat
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Change Briefs
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Empty Catheter Bag
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Empty Colostomy Bag
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Notes
Mobility
Walking alone
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Can stand up no assist
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Can stand and pivot
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Notes
Vitals
Record Blood Pressure
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Record Blood Sugar
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Record Weight
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Record Temperature
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Record Respiration / SPO2
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Notes
Medication
Medication Reminders
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Crush The Medication
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Swallowing Medications
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Placing medications in a liquid
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Use of Gait Belt
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Visual Cues
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Verbal Prompts
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Morning Medication
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Afternoon Medication
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Evening Medications
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Guide Their Hand To Put medication
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Place medications in the mouth
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Is There a Pill Organizer In The Home
Location of the Pill Organizer?
Time Meds are Passed?
Notes
Medical Supplies
Check List
Medical Wheel Chair
Hearing Aide Charger
Medical Alert Button Charger
Transport Wheel Chair
Motorized Wheel Chair
Reclining Chair
Shower Chair
Commode
Walker
Cane
Gait Belt
Urinal
Hoyer Lift
Sit to Stand
Sliding Board
Hospital Bed
Bed Rail
Shower Grab Bars
Removal Shower Head
Other
Other
Check List
Brief /​Adult Diaper (Small)
Brief /​Adult Diaper (Medium)
Brief /​Adult Diaper (Large)
Brief /​Adult Diaper (Extra Large)
Reusable Bed Pads
Disposable Bed Pads
Hand Gloves
Face Masks
Hand Sanitizer
Extra Bed Linen
Body Gowns
Bathing Wash Tub /​ Basin
Flushable Body/​Bottom Wipes
Wash Clothes
Other
Other
Notes
Long Term Care / Auto Insurance
Yes or No
File
Max. file size: 512 MB.
Policy Carrier Name
Policy Number
Claim Number
Home Health Care:
Medicare Does Not Cover Private Duty In Home Care Services
Medicare will cover 100% of your Medical Home Health Care Services.
With a Doctor prescription, we can provide a Registered Nurse, Physical Therapy, Occupational Therapy, Speech Therapy, and Home Health Aide.
Enroll Into Medicare Benefits
Yes
No
Upload Medicare Card
Max. file size: 512 MB.
Are you currently receiving your Medicare home health care benefits? Yes or No
Primary Health Insurance Name
Primary Health Insurance Number
Diabetic Instructions
Do they need insulin injections?
Yes
No
Brand Name of Glucometer
Location
Notes
Dementia Care Instructions
What type of Dementia do have?
Choose
Mild Stage
Moderate Stage
Severe Stage
Client is Wandering
Yes
No
Client is Verbal Abusive
Yes
No
Sundownerd?
Yes
No
Notes
Special Cues /​Comments To Know or Say to help re-direct
Meal Preparation
Cook a Meal
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Reheat a Meal
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Serve a Meal
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Assistance with Feeding
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Breakfast Options
Lunch Options
Dinner Options
Choose
G Tube
J Tube
Peg Tube
Notes
Light Housekeeping Instructions
Notes
Non Medical Transportation Instructions
Getting into the car?
Independent
Stand By Assistance
Partial Assistance
Total Care
N/A
Notes
Social Activities - Hobbies - Companionship
Notes
Schedule
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Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Signature
Date
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