General Assessment

Step 1 of 8 – Demographics

12%

Client Information

Client Name(Required)

First Last

Client Date of Birth(Required)

Month

Day

Year

Client Home Phone(Required)

Client Cell Number(Required)

Client Email(Required)

Client Address(Required)

Street Address Address Line 2 City State ZIP Code

Any other person living in the home:

If any other person lives in the home, can they assist the client:(Required)

Does anyone else outside of the home assist the client:

If so who and when:(Required)

Emergency Contact Name(Required)

First Last

Relationship to Client:(Required)

Emergency Contact Phone Number(Required)

Emergency Contact Email Address(Required)

Emergency Contact Address(Required)

Street Address Address Line 2 City State ZIP Code

Power of Attorney Information

Medical POA Name(Required)

Financial POA Name(Required)

Medical POA Address(Required)

Street Address Address Line 2 City State ZIP Code

Financial POA Address(Required)

Street Address Address Line 2 City State ZIP Code

Medical POA Phone – Primary

Medical POA Phone – Secondary

Financia POA Phone – Primary

Financial POA Phone – Secondary

Advance Directive(Required)

Yes

Advanced Directive Copy on File(Required)

Yes

DNR(Required)

Yes

DNR Copy on File(Required)

Yes

Medical Professionals

Primary Care Physician Name(Required)

Practice Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Office Phone(Required)

Office FAX(Required)

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

Yes

Specialist Physician Information

Specialist Physician Name(Required)

Specialty(Required)

Practice Name(Required)

Address(Required)

Street Address Address Line 2/Suite Number City State ZIP Code

Office Phone(Required)

Office FAX(Required)

Preferred Hospital(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Office Phone(Required)

Office FAX(Required)

Medical Diagnoses by a Doctor:(Required)

Health Problems that May Impact Care:(Required)

Uses Oxygen?(Required)

Yes

How much oxygen and how often:(Required)

Height(Required)

Weight(Required)

Recent Hospitalizations

Reason

Date

Press the ‘+’ icon to add an additional record.

Allergies:

Medications

Food

Environmental

Other

Please specify medication allergies:(Required)

Please specify food allergies:(Required)

Please specify environmental allergies:(Required)

Please specify other allergies:(Required)

Type of reaction:(Required)

Vision(Required)

Normal

Impaired

Legally Blind

Left Cataract

Right Cataract

Both Cataracts

Wears Glasses

Contact Lenses

Other

Please Specify Vision Condition:(Required)

Hearing(Required)

Normal

Impaired

Hard of Hearing

Hearing Aid – Left Ear

Hearing Aid – Right Ear

Hearing Aid – Both

Other

Please Specify Hearing Condition:(Required)

Bladder

Incontinent(Required)

Yes

Number of Episodes Daily:(Required)

Number of Episodes Weekly:(Required)

Other Assistance:

Catheter

Assistance with Wiping/Cleaning

Wears Depends/Protective Pads

Urinal

Bed Pan

Commode

Toilet

Management techniques:(Required)

Bowel

Incontinent(Required)

Yes

Number of Episodes Daily:(Required)

Number of Episodes Weekly:(Required)

Other Assistance:

Constipation

Diarrhea

Assistance with Wiping/Cleaning

Wears Depends/Protective Pads

Toilet

Bed Pan

Commode

Management techniques:(Required)

Bathing

Bathing Assistance:(Required)

Yes

Level of Assistance(Required)

Stand by Assist

Full Assistance

Prompting

Preferred Bathing Method:(Required)

Sponge Bath

Tub Bath

Shower

Shampoo

Lotion

Other needs:(Required)

Personal Care Assistance

Personal Care Assistance:(Required)

Yes

Personal Care Assistance Needed:

Dressing Assistance

Oral Care Assistance

Shaving Assistance

Dressing Assistance:(Required)

Full Assistance

Prompting/Cueing

Upper Body

Lower Body

Shoes & Socks

Dentures:

Top

Bottom

Partial

Shaving Assistance

Electric

Disposable

Exercise:(Required)

Sedentary (no exercise)

Mild (includes climbing stairs, occasional walk)

Moderate (2 – 3x week for at least 30 minutes or more)

Regular (4x week or more for at least 30 minutes or more)

Under the care of a Physical Therapist

Alcohol Intake:(Required)

Never

Occasionally

Daily

Several times a day

Caffeine Intake:(Required)

Never consumes caffeine products

Coffee

Tea

Cola

Copy of Exercise Instructions

Max. file size: 256 MB.

Please upload if available.

Number of cups of coffee a day:(Required)

Number of cups of tea a day:(Required)

Number of cups of cola a day:(Required)

Tobacco Use:(Required)

Yes

Previously

Tobacco Type:(Required)

Cigarettes

Cigars

Pipe

Chew

Number of Cigarettes per day:(Required)

Number of Cigars per day:(Required)

Number of Pipes per day:(Required)

Number of Chews per day:(Required)

Quit Date(Required)

MM slash DD slash YYYY

Stress Management

Do you feel stressed or anxious?(Required)

Yes

How often?(Required)

Rarely

Occasionally

Daily

Stress Reduction Techniques: How do you relax or reduce stress?

Sleep

How do you sleep:(Required)

No problems sleeping

Has difficulty sleeping

Wake up at night

How often?(Required)

Usual bedtime:(Required)

Usual wake time:(Required)

Special Routines:

History of Falls:(Required)

Yes

Date of Last Fall:(Required)

Month

Day

Year

What Occurred:(Required)

Gait:(Required)

Steady

Unsteady

Weak

Do they wear any braces or prosthesis?(Required)

Yes

If so, what is the location and the type:(Required)

Recent Injury?(Required)

Yes

Date of Last Injury:(Required)

Month

Day

Year

What Occurred:(Required)

Any Concerns Related to Safety?(Required)

Yes

Comments:

Assistive Devices:

None

Grab Bars in Bathroom

Walker

Cane

Wheelchair

Raised Toilet Seat

Shower Bench

Other

Is the client bedbound?(Required)

Yes

Any other items needed:

Home pathways:(Required)

Clear

Cluttered

In the event of an emergency, do you have an evacuation plan in place?(Required)

Yes

In the event of an emergency, where will you stay?(Required)

Shelter

Shelter with Pets

Family

Other

Provide Additional Details About Evacuation Plan Location:

Name

First Last

Relationship to Client

Address

Street Address Address Line 2 City State ZIP Code

Phone (home)

Phone (cell)

Phone (other)

Do you have the following essentials in case of an emergency or power outage?

Flashlight

Batteries

Bottled Water

Three day supply of food (non-perishable)

Emergency Services phone number

HomeCare of WV office number

Family phone number(s)

Other important phone numbers

Diet:(Required)

Regular Diet

Special Diet

On a Weight Loss Diet

Is this prescribed by a physician?(Required)

Yes

Specify:(Required)

Other Diet Restrictions:

Restricted Salt

Restricted Fat

Restricted Sugar

Restricted Fluids

Bland

Count Carbs

Soft Foods

Pureed

Thickened Liquids

Encourage Fluids

Other

Specify Other Diet Restrictions:(Required)

How much fluids?(Required)

Difficulty

Eating

Chewing

Swallowing

Dentures are loose fitting

Difficulty

Monitoring required at mealtimes

Plan and prepare meal with client

Meals on Wheels

Caregiver invited to dine with Client

Caregiver will bring own food

Caregiver should not eat with Client on this assignment

Prefer to eat meals:(Required)

At table

On a try

Other

Able to Communicate Needs(Required)

Yes

Understands Direction(Required)

Yes

Able to Make Own Decisions(Required)

Yes

Demonstrates Good Judgement(Required)

Yes

Cognitive Status:

Alert

Disoriented

Confused

Depressed

Impaired

Other

When does this occur?(Required)

How often does this occur?(Required)

Contributing Factors:(Required)

Other/Notes:(Required)

Has the client been medically evaluated?(Required)

Yes

When:(Required)

What was the diagnosis?(Required)

Source of information:(Required)

Family Obvservations:(Required)

Special Instructions:(Required)

Describe mental status/behavior problems which the provider must address and methods to be used:(Required)

Personal Care / Grooming

Requires assistance with:(Required)

Bathing

Shaving

Skin Care

Toileting

Dressing

Shampooing

Lotion

Oral Care

Hair Care

Foot Soaks

Other

Other:(Required)

Exercise / Activity

Assist with Walking

Assist with Transfers

Assist with Exercise

Household Chores

Household Chores(Required)

None

Bedroom

Bathroom

Kitchen

Common areas

Make beds

Tidy

Counters

Change & launder bedding

Towels

Personal clothing

Iron

Sweep

Wet mop

Trash

Dishes

Dishwashers

Night time turn down bed

Organize

Client provides cleaning supplies/gloves

Change & Launder Bedding Every:(Required)

Rooms off Limits:

Notes / Instructions

Transportation

Transportation:(Required)

May use client’s car

Authorization signed / Insurance information on file in office

Shopping

Errands

Church or Religious Event

Medical Appointments

Other

Caregiver to accompany client to medical appointments

Food and Fluid

Food and Fluid:(Required)

Prepare Meals & Snacks

Assist with Eating

Encourage and/or Restrict Fluids

Medication Reminders

Requires Medication Reminders?(Required)

Yes

Medication

Pill Box

Has an auto dispense machine

Pill box set up by:(Required)

Pet Information

None

Cat

Dog

Other

Other Pet(s):(Required)

Name of Vet:(Required)

Vet Phone Number:

Instructions:(Required)

Home Access

Home Access(Required)

Door unlocked

Client will let in

Other CG will let in

Garage code provided

Lock Box

Other

Garage Code(Required)

Other:(Required)

Vitals

Blood Pressure Sitting:

Blood Pressure Standing:

Blood Pressure Lying:

Pulse

Respirations

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.

Notes and Comments:(Required)