CLIENT ASSESSMENT FORM

Section A: Personal Details

Title * Full Name * Date of Birth * Age *

Gender *

Male Female Others

Marital Status *

Single Married Widowed Divorced

State of Origin * Address * Phone Number(s) * Email Address Language(s) Spoken * Weight (kg) * Height (cm) Are you receiving services from any other homecare agency? *

Section C: Latest Investigations

Latest Blood Pressure (mmHg) * Latest Fasting Blood Sugar (mg/dl) * HIV Status * HBsAg Status * HCV Status *

Section F: Risk Assessment

Falls Risk

Cognitive Status

Alert & Oriented Mild Memory Loss Dementia Confused

Behavioral Concerns (aggression, wandering, depression, etc.)

Home Environment Safety

Safe Potential Hazards

If hazards, specify

Section G: Consent & Agreement

The above information is true and correct to the best of my knowledge. I am authorizing Rockgarden Homecare Agency to conduct an in-home assessment and to provide Homecare Services for my loved one named above.

Name (Person/Institution Responsible for Payment) * Relationship with Client * Phone Number of Above * Client Next of Kin's Name * Client Next of Kin's Address * Client Next of Kin's Phone Number * Client Next of Kin's Email Signatory's Full Name * Date *

Kindly use your fingers or a stylus pen to write your signature *

Client Assessment Form

Section A: Personal Details

Section B: Medical History & Current Health

Section C: Latest Investigations

Section D: Care Needs

Section E: Social & Lifestyle Information

Section F: Risk Assessment

Section G: Consent & Agreement