(615) 717-0077
(615) 424-4376
(615) 891-7685
devotedhcinc@gmail.com
1653 Bridgecrest Dr, Antioch, TN 37013
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About
Services
Companionship
Home Health Aide
Personal Care Assistant
Homemaker
Companion/Sitter
Live-In Caregiver
Blog
Service Areas
Careers
Forms
Client Forms
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Resources
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Client Assessment
Forms
Client Assessment
Client Name:
Client Phone:
Client Address:
Doctor’s Name:
Doctor’s Phone:
Contact Person:
Contact’s Phone:
General Topics
Medical Information
Medical Conditions
Subject Matter
Action(S) Indicated
Medical Background
Major Surgeries
Illnesses
Action(S) Indicated
Hospitalizations
Recent (Last 2 Years)
Previous
Action(S) Indicated
Height & Weight
Height:
Weight:
Weight Status:
Increase
Static
Decrease
Reason for Any Weight Change
Action(S) Indicated
Vital Signs
Blood Pressure
Pulse
Respirations
Temperature
Action(S) Indicated
Medications
Medications
Action(S) Indicated
Medication Allergies
Medications
Action(S) Indicated
Current Treatments
Current Treatments
Action(S) Indicated
Current Therapy
Current Therapy
Action(S) Indicated
Dental Care
Does client have dental problems?
Yes
No
Is Client Under Care Of Dentist?
Yes
No
Dental State:
No Dentures
Full Upper
Full Lower
Partial Denture
Dentures Damaged
No Dentures
Not Wearing Dentures
No Teeth
Can Client Chew Food Effectively?
Yes
No
Dentist's Name:
Dentist’s Phone Number:
Action(S) Indicated
Vision
Vision
Unimpaired
Blind - Safe In Familiar Locale
Adequate For Personal Safety
Blind - Requires Assistance
Distinguishes Only Light Or Dark
Wears Glasses:
Yes
No
Action(S) Indicated
Hearing
Hearing
Unimpaired
Mild Impairment
Moderate Impairment But Not a Threat to Safety
Impaired –Safety threat exists.
Totally Deaf
Uses Hearing Aid(s):
Yes
No
Uses Hearing Aid(s):
Right Ear
Left Ear
Action(S) Indicated
Mental Health
Attitude
Cooperative
Indifferent
Resistive
Demanding
Suspicious
Hostile
Appearance
Well Groomed
Adequate
Disheveled
Inappropriately Dressed
Not Dressed
Self-Direction
Independent
Needs Motivation
Dependent
Needs Direction
Behavior
Normal
Wandering
Sun downing
Restless
Hostile
Withdrawn
Self Destructive
Safety Hazard
Aggressive
Verbal
Physical
Influence
Appropriate
Inappropriate
Anxious
Blunted
Euphoric
Depressed
Angry
Mood Swings
Thought Content
Normal
Delusions
Obsessions
Phobias
Persecutory
Guilt
Can’t Assess
Perceptions
Normal
Hallucinations
Auditory
Visual
Other
Cognition
Normal
Impairment
Mild
Moderate
Severe
Insight
Good
Partial
None
Judgment
Good
Adequate
Poor
Action(S) Indicated
LIVING HABITS
Smoking Habits
Client Smokes
Yes
No
Degree of Problem
No Problem
Some Problem
Major Problem
Action(S) Indicated
Alcohol Consumption
Client Drinks
Yes
No
Degree of Problem
No Problem
Some Problem
Major Problem
Action(S) Indicated
Current Diet
Current Diet
Regular
Diabetic
Low Fat
Low Salt
Vegetarian
Other
Takes Supplement (E.g. Ensure)
Action(S) Indicated
Allergies Food & Other
Allergies Food & Other
Action(S) Indicated
Eating Habits
Eating Habits
Good
Fair
Poor
Comments:
Action(S) Indicated
COMMUNCATION
Language Spoken
Language Spoken
English
French
Chinese
Japanese
Italian
Spanish
Russian
East Indian
Other
Other
Action(S) Indicated
Speech
Speech
Unimpaired
Simple Phrases - Understandable
Simple Phrases - Partially Understandable
Isolated Words – Understandable
Speech Not Understandable Or Does Not Make Sense
Does Not Speak
If Client Cannot Speak, Indicate Method of Communicating
Method is:
Effective
Partially Effective
Moderately Effective
Not Effective
Action(S) Indicated
Understanding
Understanding
Unimpaired
Understands Simple Phrases Only
Understands Key Words Only
Understanding Unknown
Not Responsive
Action(S) Indicated
ACTIVITIES OF DAILY LIVING
Mobility Aids
Mobility Aids
Uses Cane
Uses Walker
Uses Crutches
Uses Wheelchair
Uses Grab Bars
Other Prosthesis Or Aid
If Wheelchair
Manual
Electric
Other Prosthesis Or Aid:
Action(S) Indicated
Ambulation
Ambulation
Independent In Normal Environments
Independent Only In Specific Environment
Requires Supervision
Requires Occasional Or Minor Assistance
Requires significant or Continued Assistance
Action(S) Indicated
Transferring
Transferring
Independent
Needs Supervision transferring to:
Needs Intermittent Assistance transferring to:
Needs Continued Assistance transferring to:
Completely Dependent for All Movements
1st
Bed
Chair
Toilet
2st
Bed
Chair
Toilet
3st
Bed
Chair
Toilet
Action(S) Indicated
Bathing
Bathing
Independent in Bathtub or Shower
Independent with Mechanical Aids (E.g. bath seat)
Requires Minor Assistance or Supervision:
Requires Continued Assistance
Resists Assistance
Other
Untitled
Getting in and Out of Tub/Shower
Turning Taps On and Off
Washing Back
Other
Action(S) Indicated
Dressing
Dressing
Independent
Supervision or Needs some help:
Periodic or Daily Help Needed:
Untitled
Selecting Appropriate Clothing
Coordinating Colors
Untitled
Putting on Clothin
Doing up Buttons, Laces, Zippers
Pulling on Trousers, Socks, Shoes
Determining Condition or Cleanliness of Clothing
Action(S) Indicated
Grooming & Hygiene
Grooming & Hygiene
Independent
Requires Reminder, Motivation&/or Direction
Requires Assistance with Some Things
Requires Total Assistance
Resists Assistance
Untitled
Putting Toothpaste of Toothbrush
Using Electric Razor
Action(S) Indicated
Eating
Eating
Independent
Independent with Special Provision for Disability
Requires Intermittent Help With:
Untitled
Cutting Up/Pureeing Food
Must Be Fed
Resists Feeding
Action(S) Indicated
Bladder Control
Bladder Control
Totally Continent
Needs Routine Toileting or Reminder
Incontinent Due to Identifiable Factors
Incontinent Once Per Day
Incontinent More than Once per Day
Action(S) Indicated
Bowel Control
Bowel Control
Has Total Control
Needs Routine Toileting or Reminder
No Bowel Control Due to Identifiable Factors
Loses Bowel Control Once Per Day
Loses Bowel Control More than Once per Day
Action(S) Indicated
Toileting
Toileting
Requires Raised Toilet Seat or Commode
Has Difficulty With Buttons, Zippers
Needs Help with Aids (E.g. Catheter, Condom Drainage, etc.)
Other
Other
Action(S) Indicated
Exercising
Exercising
Exercises Regularly:
Time and/or Distance
Recent Changes to Exercise Regime
Exercise Alone
Exercises With Attendant
Other
Exercises Regulary
Daily
Alternate Days
Twice a Week
Weekly
Other
Other
Time and/or Distance
Recent Changes to Exercise Regime
Other
Action(S) Indicated
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Preparing Food
Preparing Food
Independent
Adequate if Ingredients Supplied
Can Make or Buy Meals But Diet is Inadequate
Physically or Mentally Unable to Prepare Food
No Opportunity to Prepare Food or Chooses Not to Prepare Food
Action(S) Indicated
Housekeeping
Housekeeping
Independent
Generally Independent But Needs Help With Heavier Tasks
Can Perform Only Light Tasks Adequately
Performs Light Tasks But Not Adequately
Needs Regular Help and/or Supervision
No Opportunity to Do Housework or Chooses Not to Do Housework
Action(S) Indicated
Shopping
Shopping
Independent
Independent But For Small Items Only
Can Shop if Accompanied
Physically or Mentally Unable to Shop
No Opportunity to Shop or Chooses Not to Shop
Action(S) Indicated
Transportation
Transportation
Uses Private Vehicle
Uses Taxi or Bus
Independent
Must be Accompanied
Must be Driven
Physically or Mentally Unable to Travel
Needs Ambulance for Transporting
Action(S) Indicated
Telephone
Telephone
Independent
Can Dial Well Known Numbers
Answers Telephone Only
Physically or Mentally Unable to Use Telephone
No Opportunity to Use Telephone or Chooses Not to Use Telephone
Action(S) Indicated
Medication/ Treatments
Medication/ Treatments
Completely Responsible for Self
Requires Reminder or Assistance
Responsible if Medications Prepared in Blister pack
Physically or Mentally Unable to Take Medications and Conduct Treatments
Resists Taking Medication or Conducting Treatments
Action(S) Indicated
ATTENDANT PROFILE
Attendant
Attendant
Independent
Needs an Attendant
Frequency of Attendant Assistance
Attendant Needs Met by:
Exercises Regulary
Intermittent
Constantly
During Day
During Night
Exercises Regulary
Spouse
Friend
Family
Other
Action(S) Indicated
SOCIAL PROFILE
Housing
Housing
House
Apartment
Condominium
Mobile Home
Room
Facility
Other
Exercises Regulary
Self Owned
Rental
Exercises Regulary
Urban
Rural
Other
Action(S) Indicated
Living Companions
Living Companions
Lives Alone
Lives with Spouse or Spousal Equivalent
Lives With Adult Children
Lives With Child(ren)
Lives with Other Adult Male
Lives with Other Adult Female
Principal Helper:
Principal Helper:
Action(S) Indicated
Religion & Culture
Religion & Culture
Ethnicity
Religion
Ethnicity
Religion
Action(S) Indicated
FINANCIAL PROFILE
Financial Benefits
Financial Benefits:
Old Age Security Pension
Guaranteed Income Supplement
Gains for Senior
War Veterans Allowance or Disability Pension
Company Pension
Other
Other
Action(S) Indicated
Financial Management
Financial Management
Self
Friend
Spouse
Public Trustee
Family
Power of Attorney
Other
Other
Action(S) Indicated
Financial Arrangements
Financial Arrangements
Appropriate
Not Appropriate
Action(S) Indicated
ADDITIONAL INFORMATION
CLIENT NAME
Assessor Name & Position (Print)
Assessor Signature
Date
MM slash DD slash YYYY
Client or Client’s Representative’s Signature
Date
MM slash DD slash YYYY
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