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Home Care Wv

Visiting Angels Beckley

General Assessment

General Assessment

Step 1 of 8 - Demographics

12%

Client Information

Client Name(Required)
Client Date of Birth(Required)
Client Address(Required)
Emergency Contact Name(Required)
Emergency Contact Address(Required)

Power of Attorney Information

Medical POA Address(Required)
Financial POA Address(Required)
Advance Directive(Required)
Advanced Directive Copy on File(Required)
DNR(Required)
DNR Copy on File(Required)

Medical Professionals

Address(Required)
Do you have a specialist that you see?(Required)

Specialist Physician Information

Address(Required)

Address(Required)
Uses Oxygen?(Required)
Recent Hospitalizations
Reason
Date
 
Press the '+' icon to add an additional record.
Allergies:
Vision(Required)
Hearing(Required)

Bladder

Incontinent(Required)
Other Assistance:

Bowel

Incontinent(Required)
Other Assistance:

Bathing

Bathing Assistance:(Required)
Level of Assistance(Required)
Preferred Bathing Method:(Required)

Personal Care Assistance

Personal Care Assistance:(Required)
Personal Care Assistance Needed:
Dressing Assistance:(Required)
Dentures:
Shaving Assistance
Exercise:(Required)
Alcohol Intake:(Required)
Caffeine Intake:(Required)
Max. file size: 256 MB.
Please upload if available.
Tobacco Use:(Required)
Tobacco Type:(Required)
MM slash DD slash YYYY

Stress Management

Do you feel stressed or anxious?(Required)
How often?(Required)

Sleep

How do you sleep:(Required)
History of Falls:(Required)
Date of Last Fall:(Required)
Gait:(Required)
Do they wear any braces or prosthesis?(Required)
Recent Injury?(Required)
Date of Last Injury:(Required)
Any Concerns Related to Safety?(Required)
Assistive Devices:
Is the client bedbound?(Required)
Home pathways:(Required)
In the event of an emergency, do you have an evacuation plan in place?(Required)
In the event of an emergency, where will you stay?(Required)

Provide Additional Details About Evacuation Plan Location:

Name
Address
Do you have the following essentials in case of an emergency or power outage?
Diet:(Required)
Is this prescribed by a physician?(Required)
Other Diet Restrictions:
Difficulty
Difficulty
Prefer to eat meals:(Required)
Able to Communicate Needs(Required)
Understands Direction(Required)
Able to Make Own Decisions(Required)
Demonstrates Good Judgement(Required)
Cognitive Status:
Has the client been medically evaluated?(Required)

Personal Care / Grooming

Requires assistance with:(Required)

Exercise / Activity

Exercise / Activity

Household Chores

Household Chores(Required)

Transportation

Transportation:(Required)

Food and Fluid

Food and Fluid:(Required)

Medication Reminders

Requires Medication Reminders?(Required)
Medication

Pet Information

Pet Information

Home Access

Home Access(Required)

Vitals

Desired Schedule

List(Required)
Day
Start Time
Ending Time
 
Click on the '+' icon at the end of the row to add a new day to the schedule.