CLIENT ASSESSMENT FORM Date:___________ Time Started: ____________ Location:________________ Time Completed: ____________ _________________________ Those Present: ___________________________ ___________________________ ___________________________ NOTES: Clients Name: _____________________ Date of Birth: _____________________ Address:____________________________ City:_______________________________ State: _____________________________ Zip: _______________________________ Phone: _____________________________ Medicare # _________________________ Private Insurance __________________ Address ____________________________ Policy # ___________________________ Phone # ____________________________ GAP Insurance ______________________ ____________________________________ ___________________________________ Doctors Name: ______________________ Address: ___________________________ City: ______________________________ State: _____________________________ Zip: _______________________________ Phone: _____________________________ Type of Medicine Practiced: ________ Hospital: __________________________ Location: __________________________ Preferred Hospital:_________________ Responsible Party: _________________ Address: ___________________________ City: ______________________________ State: _____________________________ Zip: _______________________________ Home Phone: ________________________ Business Phone: ____________________ Next of Kin:________________________ Address: ___________________________ City: ______________________________ State: _____________________________ Home Phone: ________________________ Business Phone: ____________________ Do you have an Attorney ?___________ Name:______________________________Phone:__________________ Durable Power of Attorney ?:________ Do you have a Will or Trust ?:______ PHYSICAL 1) Do you have any physical disabilities that interfere with your activities ? a) Poor Eyesight______________ b) Poor Hearing ______________ 2) Do you have any supportive devices ? a) Cane_______ c) W/C __________ b) Walker ____ d) Hearing Aid ___________ e) Other ____________________________________ 3) Do you have any physical impairments or Chronic Illnesses a) Heart Trouble _____ b) Arthritis _________ c) High Blood Pressure __________________ d) Emphysema________ Other _____________ 4) Do you have any difficulties completing daily household chores ? 5) Do you find it difficult getting down to clean floors and reach areas you use to reach ? 6) Do you have any trouble making your bed or changing your sheets ? 7) Do you find your vacuum cleaner too heavy or clumsy for you to use ? 8) Do general household chores take much of your energy ? 9) Are you able to get into and out of your shower or tub unassisted? 10) Is it hard to get into; or out of the tub or shower ? 11) Are Grabber Bars (needed) available on shower, tub, or any other areas ?_______ 12) Do you have any difficulty with dressing ? 13) Do you routinely take medications ? a) What are they ________________________________________________ ______________________________________________________________ b) How often ___________________ 14) Are you allergic to any medications ? 15) What method do you use to assure that you don't forget to take your medication, or that you don't take it too often ? ______________________ NUTRITIONAL NEEDS 1) Are you on a special diet for Medical reasons ? 2) What do you eat for a typical: Breakfast ______________________________________ Lunch ________________________________________ Dinner _______________________________________ 3) How often do you grocery shop ? ______________________ 4) Do you do your own shopping, or does someone shop for you ? ________________ 5) Is it difficult for you to prepare full meals ? ________________ 6) Is it easier to just have a snack at mealtime instead of preparing a meal ?__________________ 7) Do you find food sometimes spoils before you are able to use it ?____________ 8) Do you like most foods, or are you more choosy about what you eat ? _________________ 10) Do you enjoy meals more when someone else prepares them ? ________________________ 11) Do you look forward to eating meals out with family or friends ?___________________ 12) Do you sometimes leave things cooking on the stove, and forget about it ? ______________ 13) Do you ever forget, and leave the water running ? ______ 14) Do you ever let the tea pot run dry ?________________ 15) Would you eat more often if you had someone to cook for you ? __________ 16) Would you like someone to bring a hot meal to your home at noon-time ? ____ HOME SAFETY 1) Do you use an electric blanket, electric mattress pad or heating pad ?______________ 2) Do you ever forget to turn the electric blanket, electric mattress pad, or heating pad off ? 3) Do you use throw rugs ? 4) How many sets of stairs are there in your home that you must climb each day ? 5) Are they difficult for you to climb ? 6) If you should fall, how would you get help ? 7) How many telephones do you have ? __________. Where are they located ? 8) Are emergency and family phone numbers readily available if you need them ? 9) Do you have dead-bolt locks on your doors ? __________. Do you keep your doors locked at all times ? TRANSPORTATION 1) Do you drive a car ? ________________. How often do you drive ? ______________ 2) Have you had any difficulties driving ?, such as traffic citations, accidents, etc. ? 3) Would you prefer not to drive if you could be taken to appointments and shopping by someone else . 4) Do you skip social functions, or change your plans because you don't feel like driving that day ? MENTAL STATUS/MEMORY/JUDGMENT 1) What is your age ? ________ Birthdate ? __________ 2) How many siblings do you have ? How many, are;(or were) older/younger ? 3) What is the name of our President ? 4) What is today's date ? Month - Day - Year ? 5) What are your children names and ages ? 6) When was your last Doctors' visit ? 7) What would you do if a stranger came to your door and asked to use your phone because their car broke down ? 8) Someone calls you on the phone and says they are the vice-president of your bank, and asks you to withdraw $ 3000 to help them catch a bank employee who has been stealing from the Bank. What would you do ? FINANCES 1) Do you write checks for monthly bills ? 2) Do you ever forget to send out a bill when it is due ?______________. 3) Is your monthly paperwork overwhelming ? 4) Would it be helpful if someone else took care of bill paying for you ? HOUSEHOLD MAINTENANCE 1) Who does needed house repairs and yardwork ? 2) Would it be helpful if someone took care of them for you ? SOCIAL 1) How many Church and Social groups do you belong to ? 2) On an average - how many times a week do you attend social functions, or church ? 3) How many times a week do you go out for lunch or shopping ? ___. With or without friends ? 4) How many times a week do you have visitors ? ____ 5) Does time seem to go slowly for you ? 6) Do you ever feel alone or lonely ? _____ 7) Do you sometimes wish you had someone to talk to that would really listen to you ? 8) Do you sometimes have trouble getting up in the morning, or find yourself sleeping later because you don't have a reason to get up ? 9) Do you think you would enjoy a Senior Center where you could go during the day and be involved in activities with other older adults like yourself ? ADDITIONAL RELEVANT OBSERVATIONS: