Client Name

First Name

Last Name

Phone

(###)

###

####

Date

MM

DD

YYYY

1. Have you received any of the following preventive health? Y/N

If yes check all that apply

Physical Exam (Annually)

Flu Vaccine (Annually)

Pneumonia Vaccine (Age 60+)

Zoster (Shingles) Vaccine (Age 50+, given once)

Colorectal Cancer Screening (Age 50+)

Female preventive health care: mammogram (Female only, Age 40+)

Female preventive health care: pap smear or other exams such as ultrasound (Female only, Initial age 21 then every 3 years up to age 65)

Bone Density Scan (Age 40+)

Vision Exam (Every 2 years)

Dental Exam (Annually)

2. Have you experienced any of the following in the last twelve (12) months? Y/N

If yes check all that apply

Unplanned weight loss of 10 or more lbs.

Unplanned weight gain of 10 or more lbs.

Two (2) or more falls

Problems with skin breakdown

3. Do you have any health concerns?

Yes, I do but needs are being addressed

Yes, I do and needs are not being addressed

Maybe, I am not sure

No, I do not

4. Have you seen any physicians and specialists in the past twelve (12) months? Y/N

If yes check all that apply

Allergist

Audiologist

Cardiologist

Chiropractor

Dentist

Dermatologist

Dietician

Ear/Nose/Throat

Endocrinologist

Gastroenterologist

Gynecologist

Hematologist

Homeopathic Physician

Licensed Clinical Social Worker

Licensed Mental Health Counselor

Nephrologist

Neurologist

Neurosurgeon

Obstetrician

Oncologist

Ophthalmologist

Orthopedist

Pain Management

PCP: Family Practice

PCP: Internal Medicine

PCP: Pediatrician

Physiatrist

Podiatrist

Psychiatrist

Psychologist

Pulmonologist

Rheumatologist

Surgeon

Urologist

Other

5. Have you been to an Urgent Care Center in the past twelve (12) months?

If "Yes" indicate When and Why (List all)

Yes

No

6. Have you been to an Emergency Room in the past twelve (12) months?

If "Yes" indicate When, Why and if Admitted? (List all)

Yes

No

7. Have you been admitted to the hospital in the past twelve (12) months?

If "Yes" indicate When and Why-Admission/Discharge Dates (List all)

Yes

No

8. Have you been Baker Acted in the past twelve (12) months?

If "Yes" indicate When and Why (List all)

Yes

No

9. Have Reactive Strategies under 65G-8 been used due to behavioral concerns in the past twelve (12) months?

If "Yes" indicate When and Why (List all)

Yes

No

10. Has the Abuse Hotline been contacted by you or others to report abuse, neglect, or exploitation in the past twelve (12) months?

If "Yes" indicate When and Why (List all)

Yes

No

11. Do you feel you need any of the following therapies that you do not currently receive? Y/N

If "Yes" Comment box is provided

Occupational Therapy

Speech Therapy

Physical Therapy

Massage Therapy

Nutritional Support

12. Do you feel you need any of the following assessments? Y/N

If yes check all that apply

Adaptive Equipment Evaluation

Oral Motor Evaluation

Swallow Study

Specialized Mental Health Assessment

Behavior Assessment

Environmental Accessibility Assessment

Medication Review

Nursing Evaluation

13. Do you use adaptive devices or equipment? Y/N

If yes check all that apply

Glasses

Hearing Aids

Dentures

Wheelchair/scooter

Communication Device

Mobility Aids (Hoyer Lifts, Van lifts, Walker, Cane)

Personal Safety Equipment (Helmet, braces/splints)

Home Safety Equipment (Hoyer Lift, Grab bars, Ramps, shower chair)

Mealtime Aids (adaptive utensils, plates, cups, chairs)

Other

14. Is your adaptive device or equipment in good working condition? Y/N/NA

If “No” provide details in comments section.

Yes

No

N/A

15. Do you have an emergency disaster plan in place?

Yes

No

Have your been educated about abuse, neglect and exploitation?

Yes

No

We would like to know?:

Are you satisfied with the services provided by your current Home Health Aid?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Are you satisfied with the service provided by AdelCare office staff?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree