Client Inquiry Assessment

Client Inquiry Assessment.

Date (*)

Invalid Input
Would like to start services/move? (*)

Invalid Input
Client First Name (*)

Please type your full name.
Client Last Name

Please type your full name.
Client Age

Invalid Input

Responsible Family Member

First Name (*)

Invalid Input
Last Name

Invalid Input
DPA? (*)

Invalid Input
Relationship to Client (*)

Invalid Input
Home Phone (*)

Invalid Input
Cell Phone

Invalid Input
Address (*)

Invalid Input
City (*)

Invalid Input
State (*)

Invalid Input
Zip Code (*)

Invalid Input
E-mail (*)

Invalid Input
Preferred Contact Method (*)

Invalid Input
Permission to give client's name and phone number to potential communities? (*)

Invalid Input
Proposed length of service? (*)

Invalid Input
Preferred Area/Location (explain as necessary, i.e. zip code, city) (*)

Invalid Input
Support Systems (check all that apply) (*)






Invalid Input
Current Living Arrangement (*)

Invalid Input
How Long?

Invalid Input
Clients Primary Diagnosis (*)

Invalid Input

Medication

General Medications (*)

Invalid Input
Are All Medications Taken by Mouth?

Invalid Input
If "No", Please Explain (i.e. insulin by injection)

Invalid Input
Using Oxygen

Invalid Input
Approx. Height

Invalid Input
Approx. Weight

Invalid Input
Diet

Invalid Input
Mobility







Invalid Input
Smoker

Invalid Input

Activities of Daily Living (ADL's)
To the best of your knowledge, please indicate the level of assistance needed in each of the following areas: (0=No Assistance Need, 1=Supervision/Monitoring, 2=Supervision/Occasional Assistance, 3=Moderate Assistance Needed, 4=Progressed Assistance, 5=Total Care)


  


Please note: Residential Care/Assisted Living Communities are regulated by the state of California. Because these communities are considered 'non-medical' there are certain medical conditions prohibitive for admission, including feeding tubes, tracheostomies

Now serving families and licensed communities throughout the San Joaquin Valley: Modesto - Bakersfield

559.435.8138 - Office
661.829.4396 - Office
559.435.7868 - Fax
559.304.4124 - Cell

info@residentialhomecare.com

City Wide Tour

Ever wanted to ask questions about elder care, but didn’t know who, what, or how; or were just too ‘afraid’ to ask?

Checklists

Consumer checklist's of important services, and accommodations in local residential care communities for the elderly.

Increase Communication With Your Loved Ones

With ACN Digital Phone Service, seeing is believing! Add a video phone and enjoy a real-time, true-to-life video experience that will change the way you communicate. More info here.