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Online Assessment Form
Online Assessment Form
Please Fill in all fields below
Fields marked with
*
are Required!
Name
*
Email address
*
Address
Please include: State, Postcode, Address, Country
Phone (Work)
Phone (Home)
Fax
1. The person you are requesting this information for is:
Self
Spouse
Parent
Sister / Brother
Grandparent
Aunt / Uncle
Child
Friend
Other
2. Age:
3. When is care needed :
Immediately
2-3 weeks
4-6 weeks
1 year
Other
4. Support System :
Living with relatives / friends
Living close to relative / friends who check-in
Relatives / friends live out of town but visit
No relatives or friends
5. How mobile is this person:
No problems with mobility
Stumble from time to time
Fallen recently
Difficulty walking up stairs
Use cane or walker for security
Need help to get out of a chair
Not certain
6. Personal Care Needs (check all that apply ):
Do not have any personal care needs at this time
Needs assistance getting dressed and undressed
Needs assistance getting in and out of bathtub / washing hair / brushing hair / cleaning teeth / shaving, etc.
Needs assistance using the commode and / or incontinence management products
Not certain
7. Homemaking Needs (check all that apply ):
Shopping / buying groceries
Cleaning / laundry
Cooking meals
Running errands / escort to medical appointments
Companionship
Not certain
8. Nutritional Needs:
Able to shop, prepare and maintain a healthy, balanced diet
Requires assistance with planning, shopping and preparation
Requires food to be prepared but can eat own meals
Needs asistance preparing and eating meals
Requires tubal or intravenous nutrition
Not certain
9. How many different prescription medications does this person take?
No prescriptions taken at this time
One a day
Two or three per day
More than 4 per day
Not certain
10. Home safety environment
Able to safely maintain current residence independently
Needs occasional assistance with outside home maintenance
Needs frequent assistance with maintaining a safe, comfortable environment
Always needs assistance at home with maintenance and safety
Not certain
11. Cognitive Ability
Is aware of surroundings (time, place and person)
Needs occasional reminders of surroundings
Needs frequent reminders of surroundings
Is unaware of surroundings
Not certain
12. Psychological or mental well-being
Psychologically stable, well adjusted and conducts self appropriately
Exhibits signs of depression, confusion or anxiety
Exhibits signs of inappropriate behaviour such as verbal abuse, agitation or physical aggression towards others
Not certain
13. Health Problems (check all that apply):
Arthritis
Cancer
Stroke
Heart disease
Open wounds
Alzheimer's or dementia
Pain
Parkinson's disease
Diabetes
Brain injury
Lung problem
Recovering from surgery
None
14. Current level of assistance
Currently not receiving any assistance
Currently receiving some assistance from family / friends
Currently receiving support trough government agency
Receiving support through private insurance
Currently paying privately for assistance
Not certain
Home Health Services > Online Assessment Form 
Home Health Services > Online Assessment Form