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Client Information
Personal Information
First Name
Last Name
Goes By
Birth Date
MM slash DD slash YYYY
Gender
Male
Female
Contact Information
Line 1
Line 2
Address
City
State
Zip Code
Home Phone
Mobile Phone
Care Instructions
Level of Care
Active
Total
Standby
Advance Directive
Yes
No
Advance Directive Notes
DNR
Yes
No
DNR Notes
Schedule Information
Start Date
MM slash DD slash YYYY
Schedule Comments
Responsible Parties
Responsible Party #1
Personal Information
Name
Relationship
Birth Date
MM slash DD slash YYYY
Address
Line 1
Line 2
Address
City
State
Zip Code
Contact Information
Email
Phone
Home
Mobile
Phone
Phone
Home
Mobile
Phone
Authorizations
Medical Decisions
Yes
No
HIPAA Disclosure Authorization
Yes
No
Responsible Party #2
Personal Information
Name
Relationship
Birth Date
MM slash DD slash YYYY
Address
Line 1
Line 2
Address
City
State
Zip Code
Contact Information
Email
Phone
Home
Mobile
Phone
Phone
Home
Mobile
Phone
Authorizations
Medical Decisions
Yes
No
HIPAA Disclosure Authorization
Yes
No
Responsible Party #3
Personal Information
Name
Relationship
Birth Date
MM slash DD slash YYYY
Address
Line 1
Line 2
Address
City
State
Zip Code
Contact Information
Email
Phone
Home
Mobile
Phone
Phone
Home
Mobile
Phone
Authorizations
Medical Decisions
Yes
No
HIPAA Disclosure Authorization
Yes
No
Health Care Providers
Preferred Care Providers
Preferred Hospital
Preferred Home Health Agency
Preferred Hospice Agency
Other Provider
Insurance
Long Term Care Insurance
Yes
No
Contact
Phone
Fax
Insurance Policy Number
Assessment Criteria
General Assessment
Height (ft)
Height (in)
Weight
Client alert and oriented?
Yes
No
Home environment safe and secure?
Yes
No
Client has adequate nutrition?
Yes
No
Access to proper nutrition?
Yes
No
Access to proper medical care?
Yes
No
Signs of abuse?
Yes
No
Reported abuse?
Yes
No
Medical History
Vision Issues
Yes
No
Speaking Issues
Yes
No
Breathing Issues
Yes
No
Heart Issues
Yes
No
Blood Pressure Issues
Yes
No
Circulation Issues
Yes
No
Bed Bound
Yes
No
Paralysis
Yes
No
Cancer
Yes
No
Arthritis
Yes
No
Diabetes
Yes
No
Dementia
Yes
No
Seizures
Yes
No
Hearing Loss
Yes
No
Tremors
Yes
No
Stroke
Yes
No
Alzheimer's
Yes
No
Wounds
Yes
No
Recent Surgery
Yes
No
Incontinence
Yes
No
Chronic Pain
Yes
No
Allergies
Yes
No
Fall Risk/Imbalance
Yes
No
Parkinson's
Yes
No
Supportive Devices
Dentures
Yes
No
Hospital Bed
Yes
No
Glasses
Yes
No
Ramp
Yes
No
Hearing Aid
Yes
No
Transfer Board
Yes
No
Mobility Cart
Yes
No
Cane
Yes
No
Raised Toilet Seat
Yes
No
Raised Furniture
Yes
No
Bed Rails
Yes
No
Hand-held Shower
Yes
No
Wheelchair
Yes
No
Lift Chair
Yes
No
Bedside Commode
Yes
No
Oxygen
Yes
No
ERS
Yes
No
Shower Chair
Yes
No
Grab Bars in Bathroom
Yes
No
Walker
Yes
No
Adult Diapers
Yes
No
Mechanical Lift
Yes
No
Baby Monitor
Yes
No
Other
Yes
No
Services
Meal Preparation
Yes
No
Medication Reminders
Yes
No
Light Housekeeping
Yes
No
Companionship
Yes
No
Laundry
Yes
No
Make Bed
Yes
No
Bathing
Yes
No
Hygiene Assistance
Yes
No
Transfer
Yes
No
Provider Car
Yes
No
Appointments / Errands
Yes
No
Client Car
Yes
No
Individualized Service Plan
Client Schedule
SUN
MON
TUE
WED
THU
FRI
SAT
ADLs
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Ambulation
Ambulation (Sun)
Ambulation (Mon)
Ambulation (Tue)
Ambulation (Wed)
Ambulation (Thu)
Ambulation (Fri)
Ambulation (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Apply Lotion
Apply Lotion (Sun)
Apply Lotion (Mon)
Apply Lotion (Tue)
Apply Lotion (Wed)
Apply Lotion (Thu)
Apply Lotion (Fri)
Apply Lotion (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist with Urinal
Assist with Urinal (Sun)
Assist with Urinal (Mon)
Assist with Urinal (Tue)
Assist with Urinal (Wed)
Assist with Urinal (Thu)
Assist with Urinal (Fri)
Assist with Urinal (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist Eating
Assist Eating (Sun)
Assist Eating (Mon)
Assist Eating (Tue)
Assist Eating (Wed)
Assist Eating (Thu)
Assist Eating (Fri)
Assist Eating (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist Shaving
Assist Shaving (Sun)
Assist Shaving (Mon)
Assist Shaving (Tue)
Assist Shaving (Wed)
Assist Shaving (Thu)
Assist Shaving (Fri)
Assist Shaving (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist to Commode
Assist to Commode (Sun)
Assist to Commode (Mon)
Assist to Commode (Tue)
Assist to Commode (Wed)
Assist to Commode (Thu)
Assist to Commode (Fri)
Assist to Commode (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist with exercise
Assist with exercise (Sun)
Assist with exercise (Mon)
Assist with exercise (Tue)
Assist with exercise (Wed)
Assist with exercise (Thu)
Assist with exercise (Fri)
Assist with exercise (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Assist with walking
Assist with walking (Sun)
Assist with walking (Mon)
Assist with walking (Tue)
Assist with walking (Wed)
Assist with walking (Thu)
Assist with walking (Fri)
Assist with walking (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Bathing/Tub, shower or partial
Bathing/Tub, shower or partial (Sun)
Bathing/Tub, shower or partial (Mon)
Bathing/Tub, shower or partial (Tue)
Bathing/Tub, shower or partial (Wed)
Bathing/Tub, shower or partial (Thu)
Bathing/Tub, shower or partial (Fri)
Bathing/Tub, shower or partial (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Bathroom Cleanup
Bathroom Cleanup (Sun)
Bathroom Cleanup (Mon)
Bathroom Cleanup (Tue)
Bathroom Cleanup (Wed)
Bathroom Cleanup (Thu)
Bathroom Cleanup (Fri)
Bathroom Cleanup (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Change Bed Linens
Change Bed Linens (Sun)
Change Bed Linens (Mon)
Change Bed Linens (Tue)
Change Bed Linens (Wed)
Change Bed Linens (Thu)
Change Bed Linens (Fri)
Change Bed Linens (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Change the Sheets
Change the Sheets (Sun)
Change the Sheets (Mon)
Change the Sheets (Tue)
Change the Sheets (Wed)
Change the Sheets (Thu)
Change the Sheets (Fri)
Change the Sheets (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Clean living areas
Clean living areas (Sun)
Clean living areas (Mon)
Clean living areas (Tue)
Clean living areas (Wed)
Clean living areas (Thu)
Clean living areas (Fri)
Clean living areas (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Client Dr. Appointment
Client Dr. Appointment (Sun)
Client Dr. Appointment (Mon)
Client Dr. Appointment (Tue)
Client Dr. Appointment (Wed)
Client Dr. Appointment (Thu)
Client Dr. Appointment (Fri)
Client Dr. Appointment (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Client Errands
Client Errands (Sun)
Client Errands (Mon)
Client Errands (Tue)
Client Errands (Wed)
Client Errands (Thu)
Client Errands (Fri)
Client Errands (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Client Transportation
Client Transportation (Sun)
Client Transportation (Mon)
Client Transportation (Tue)
Client Transportation (Wed)
Client Transportation (Thu)
Client Transportation (Fri)
Client Transportation (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Companionship
Companionship (Sun)
Companionship (Mon)
Companionship (Tue)
Companionship (Wed)
Companionship (Thu)
Companionship (Fri)
Companionship (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Cooking
Cooking (Sun)
Cooking (Mon)
Cooking (Tue)
Cooking (Wed)
Cooking (Thu)
Cooking (Fri)
Cooking (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Cutting Food
Cutting Food (Sun)
Cutting Food (Mon)
Cutting Food (Tue)
Cutting Food (Wed)
Cutting Food (Thu)
Cutting Food (Fri)
Cutting Food (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Dishwashing
Dishwashing (Sun)
Dishwashing (Mon)
Dishwashing (Tue)
Dishwashing (Wed)
Dishwashing (Thu)
Dishwashing (Fri)
Dishwashing (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Dispose of garbage
Dispose of garbage (Sun)
Dispose of garbage (Mon)
Dispose of garbage (Tue)
Dispose of garbage (Wed)
Dispose of garbage (Thu)
Dispose of garbage (Fri)
Dispose of garbage (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Exercise reminders
Exercise reminders (Sun)
Exercise reminders (Mon)
Exercise reminders (Tue)
Exercise reminders (Wed)
Exercise reminders (Thu)
Exercise reminders (Fri)
Exercise reminders (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Fall Risk
Fall Risk (Sun)
Fall Risk (Mon)
Fall Risk (Tue)
Fall Risk (Wed)
Fall Risk (Thu)
Fall Risk (Fri)
Fall Risk (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Feeding
Feeding (Sun)
Feeding (Mon)
Feeding (Tue)
Feeding (Wed)
Feeding (Thu)
Feeding (Fri)
Feeding (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Grooming
Grooming (Sun)
Grooming (Mon)
Grooming (Tue)
Grooming (Wed)
Grooming (Thu)
Grooming (Fri)
Grooming (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Hair Care
Hair Care (Sun)
Hair Care (Mon)
Hair Care (Tue)
Hair Care (Wed)
Hair Care (Thu)
Hair Care (Fri)
Hair Care (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Homemaker
Homemaker (Sun)
Homemaker (Mon)
Homemaker (Tue)
Homemaker (Wed)
Homemaker (Thu)
Homemaker (Fri)
Homemaker (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Hoyer Lift Assist
Hoyer Lift Assist (Sun)
Hoyer Lift Assist (Mon)
Hoyer Lift Assist (Tue)
Hoyer Lift Assist (Wed)
Hoyer Lift Assist (Thu)
Hoyer Lift Assist (Fri)
Hoyer Lift Assist (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Hygiene Assistance
Hygiene Assistance (Sun)
Hygiene Assistance (Mon)
Hygiene Assistance (Tue)
Hygiene Assistance (Wed)
Hygiene Assistance (Thu)
Hygiene Assistance (Fri)
Hygiene Assistance (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Incontinence Care
Incontinence Care (Sun)
Incontinence Care (Mon)
Incontinence Care (Tue)
Incontinence Care (Wed)
Incontinence Care (Thu)
Incontinence Care (Fri)
Incontinence Care (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Kitchen Cleanup
Kitchen Cleanup (Sun)
Kitchen Cleanup (Mon)
Kitchen Cleanup (Tue)
Kitchen Cleanup (Wed)
Kitchen Cleanup (Thu)
Kitchen Cleanup (Fri)
Kitchen Cleanup (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Laundry
Laundry (Sun)
Laundry (Mon)
Laundry (Tue)
Laundry (Wed)
Laundry (Thu)
Laundry (Fri)
Laundry (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Light Housekeeping
Light Housekeeping (Sun)
Light Housekeeping (Mon)
Light Housekeeping (Tue)
Light Housekeeping (Wed)
Light Housekeeping (Thu)
Light Housekeeping (Fri)
Light Housekeeping (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Make Bed
Make Bed (Sun)
Make Bed (Mon)
Make Bed (Tue)
Make Bed (Wed)
Make Bed (Thu)
Make Bed (Fri)
Make Bed (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Meal Preparation
Meal Preparation (Sun)
Meal Preparation (Mon)
Meal Preparation (Tue)
Meal Preparation (Wed)
Meal Preparation (Thu)
Meal Preparation (Fri)
Meal Preparation (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Medication Reminders
Medication Reminders (Sun)
Medication Reminders (Mon)
Medication Reminders (Tue)
Medication Reminders (Wed)
Medication Reminders (Thu)
Medication Reminders (Fri)
Medication Reminders (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Positioning
Positioning (Sun)
Positioning (Mon)
Positioning (Tue)
Positioning (Wed)
Positioning (Thu)
Positioning (Fri)
Positioning (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Range of Motion Exercises
Range of Motion Exercises (Sun)
Range of Motion Exercises (Mon)
Range of Motion Exercises (Tue)
Range of Motion Exercises (Wed)
Range of Motion Exercises (Thu)
Range of Motion Exercises (Fri)
Range of Motion Exercises (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Shampoo Hair
Shampoo Hair (Sun)
Shampoo Hair (Mon)
Shampoo Hair (Tue)
Shampoo Hair (Wed)
Shampoo Hair (Thu)
Shampoo Hair (Fri)
Shampoo Hair (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Taking client to appointment
Taking client to appointment (Sun)
Taking client to appointment (Mon)
Taking client to appointment (Tue)
Taking client to appointment (Wed)
Taking client to appointment (Thu)
Taking client to appointment (Fri)
Taking client to appointment (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Toileting Assistance
Toileting Assistance (Sun)
Toileting Assistance (Mon)
Toileting Assistance (Tue)
Toileting Assistance (Wed)
Toileting Assistance (Thu)
Toileting Assistance (Fri)
Toileting Assistance (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Transferring
Transferring (Sun)
Transferring (Mon)
Transferring (Tue)
Transferring (Wed)
Transferring (Thu)
Transferring (Fri)
Transferring (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Turn Client
Turn Client (Sun)
Turn Client (Mon)
Turn Client (Tue)
Turn Client (Wed)
Turn Client (Thu)
Turn Client (Fri)
Turn Client (Sat)
Always
As Needed
Specific Times
Never
Functional Level
Total Care
Extended
Limited
Frequency
Daily
Weekly
Well Being Observation
Well Being Observation (Sun)
Well Being Observation (Mon)
Well Being Observation (Tue)
Well Being Observation (Wed)
Well Being Observation (Thu)
Well Being Observation (Fri)
Well Being Observation (Sat)
Always
As Needed
Specific Times
Never
Attributes
Smoker
Yes
No
Does client smoke
Cat Friendly
Yes
No
Have cat
Transportation
Yes
No
Need transportation
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