Patient Intake Form
Emergency Contact
Decision maker name, power of attorney, conservator
Decision maker contact number, power of attorney, conservator
Name of Doctor
Doctor Contact Number
Doctor Address
Referred by:
Care Requested
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Live In - Care where the caregiver must be able to get a full nights sleep, and is also entitled to two hours off during the day. If the client cannot be left alone, relief is necessary for the caregiver to get his/her break. If the client wakes too often for the caregiver to get a full nights sleep, an overnight person may be necessary.
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24 Hour care is for intensive, around the clock coverage.
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Hourly Care is for certain periods of coverage.
Allergies to food or medications
Allergies Listed
Is the client confused or forgetful?
Prescriptions and non-prescriptions drugs please list below with proper dosage, time taken, and special instructions. e.g. (do not take on an empty stomach). This will allow our caregivers to ensure proper care.
Dietary Restrictions
Dietary Restrictions
Is patient able to walk?
Is patient capable of staying alone?
Does patient smoke?
If you selected Live in care please answer the following questions.
1. What time does the patient wake up?
2. What time does the patient take his or her meals?
3. What time does the patient go to bed?
4. What activities is the client able to engage in, and what activities is the client unable to perform that they may attempt anyway? Please list below:
What are the patients preferred recreations? Does he/she like to take a walk, be wheeled to the park, what can the caregiver do to help patient enjoy his/her day?
Is the caregiver required to drive?
Is it often difficult to get a live in caregiver who drives, as many do live in because they do not drive?
The caregiver must be fed on live in case, one reason why the fee is lower. Who is in charge of shopping for groceries? How often is grocery shopping done?
List any other comments, remarks, or other important information necessary.
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