Pre-Assessment Form

Name of the person receiving care *

First

Last

Address *

The address will help us determine if we service the area.

Gender *

Ethinicity

Year of Birth

Height

Weight

Name of the person to contact *

First

Last

Phone number *

Goal of service *

Please tell us what you want the care to accomplish

What day are you wanting to receive services?

What areas of daily living assistance do you need help with? Check all that apply.

Rate your hearing level

Rate your vision

Rate your speech

Other areas. Check all that apply.

Toileting needs. Check all that apply.

Ambulation/walking needs. Check all that apply.

Transfer

Currently receiving service from?

Briefly describe your daily routine on a typical day.

Please include your routine in the morning, afternoon, and evening. This will help us to build your routine into your care plan.

What activities do you enjoy at home?

e.g. reading, board games, hobbies, etc. This will help us to build active leisure activities into your care plan.

What activities do you enjoy outside of home?

e.g. parks, gardens, outings, church, etc. This will help us to build active leisure activities outside of your home into your care plan.

How will you pay for care?

If none of the above will pay for care, please enter the alternative payment source below.

Major diagnoses? Check all that apply.