INITIAL ASSESSMENT FORM

Client Personal Information & Background

First name

Last name

Date of Birth

Month

Day

Year

Phone

Social Security Number

Primary Residence Address

Living Arrangement Details

Emergency Contacts (Minimum of Four)

1.) Name

Relationship

Phone

2.) Name

Relationship

Phone

3.) Name

Relationship

Phone

4.) Name

Relationship

Phone

Primary Healthcare Providers' Information

Name

Contact

Insurance Details

Type

Policy #

Long-Term Care Insurance (if applicable)

VA Benefits

Power of Attorney or Legal Representative (if applicable)

Name

Phone #

Email:

Health and Medical Assessment

Current Medical Conditions and Diagnoses

Medication List and Management Needs

Medication Name

Dosage

Frequency

Time Taken

Mobility Status

Use of Assistive Devices

Recent Hospitalizations or Major Medical Events

Allergies and Dietary Restrictions

Cognitive Status

Diagnosed Memory Conditions (if any)

Vision and Hearing Status

Long answer

Fall History (Past Year)

Daily Living Activities Assessment

Personal Hygiene Preferences and Assistance Needs

Bathing Schedule and Preferences

Grooming Routines

Dressing Assistance Requirements

Meal Preparation and Dietary Needs