New Client Questionnaire Step 1 of 11 9% Getting StartedPoint of Contact Name First Last Point of Contact PhonePoint of Contact Email Point of Care Name First Last Point of Care Relationship Point of Care DetailsStart of Care Month Day Year Date of Birth Month Day Year Point of Care PhonePoint of Care Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Care PhysicianName of Physician Phone Emergency ContactEmergency Contact First Last PhoneEmail Medical InformationPrincipal Diagnosis Check All That Apply Companionship Amputation Incontinence Complete Bedrest Up as Tolerated Cane Ambulation Legally Blind Transfer Bed/Chair Exercise Prescribed Walker Wheelchair No Restrictions Partial Weight Bearing Independent At Home Oriented Forgetful Depressed Lethargic Agitated Disoriented Other Other MobilityGeneral Mobility Assist with Ambulation Assist with Transfers Bed/Chair Only Toileting Bathroom Bedpan Urinal Bedside Commode Bathing Showering Partial Sponge Bath Sink Other Skin Care Moisturizer Powder Other Bathing Other: Skin Care Other: Vision Wears Glasses Peripheral Only Vision Loss Left Vision Loss Right Hearing Hard of Hearing Wears Hearing Aid Deaf Hair Care Wash and Dry Wash and Set Comb and Brush Only Oral Care Denture Care Brush and Floss Shaving Shave Face Electric Razor Safety Razor Nail Care Clean File and Trim Polish Dressing Dresses Self Help Select Clothes Assist with Dressing Housekeeping None Light Normal Heavy Housekeeping Instructions Diet & NutritionDiet/Nutrition Regular Diet Diabetic Diet Low Sodium Liquid Only Assist with Meals Where does the client like to sit when he/she eats?BreakfastWhat foods does the client like or dislike?LunchWhat foods does the client like or dislike?DinnerWhat foods does the client like or dislike?SnackWhat foods does the client like or dislike? PetsList Each Dog or Cat:Name of PetType of AnimalSize of AnimalAre they friendly? Add RemoveShould we feed the pets? Do we need to change litter boxes or let pets outside? ShoppingTransportation Does Client Drive? Caregiver May Take Out Call Before Taking Out Accompany on Bus Waiver of Liability on File What store do they use? How do they prefer to pay? Cash Check Credit Card Will the client go with the caregiver or just give the caregiver a shopping list? Physical TherapyDo we take them to a facility or do they perform therapy at home? Is there a sheet of instructions explaining exercises – how to do and how often? Are there other hobbies or interests we can help them engage in? Payment InformationWhat method would you like to use for regular payments? Check Credit/Debit Card How would you like to pay the deposit? Check Credit/Debit Card Upload Check Image for Office ReferenceMax. file size: 512 MB. Δ
