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Client Services Application

Client Basics

First name*

Last name*

Email*

Phone*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Birthday*

Month

Day

Year

Is the client the primary contact/caregiver?*

Yes

No

Height*

Weight*

Is the client a smoker?*

Yes

No

Does the client drive?*

Yes

No

Does the client live alone?*

Yes

No

Is the client homebound?*

Yes

No

Is the client able to manage their medications?*

Yes

No

Does the client have any pets?*

Yes

No

Is the client returning from a hospital or rehabilitation center stay?*

Yes

No

Does the client have any allergies?*

Yes

No

Does the client drink alcohol?

Yes

No

Diagnosis or current health issues*

Prescribed medications*

Levels of assistance

Please select if the client is either fully Independent, needs Partial Assistance, or Full Assist in relation to the following instances.

Bathing/Showering*

Grooming*

Dressing*

Using the restroom*

Laundering *

Meal preparation*

Limitations

Speech Limitations?*

None

Partial

Total

Sight Limitations?*

None

Partial

Total

Mobility

Hand and forearm mobility*

Full

Partial

No mobility

Shoulder and neck mobility*

Full

Partial

No mobility

Leg and feet mobility*

Full

Partial

No mobility

Mood stability

How often is Client alert?*

Always

Sometimes

Never

Anxiety*

Always

Sometimes

Never

Agitation*

Always

Sometimes

Never

Short-term memory loss*

Always

Sometimes

Never

Depression*

Always

Sometimes

Never

Impaired judgement*

Always

Sometimes

Never

Danger to self*

Always

Sometimes

Never

Danger to others*

Always

Sometimes

Never

Trouble sleeping?*

Always

Sometimes

Never

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