{"id":1650,"date":"2021-02-01T20:29:57","date_gmt":"2021-02-01T20:29:57","guid":{"rendered":"https:\/\/rockgardenehr.com\/blog\/?page_id=1650"},"modified":"2025-08-30T13:29:55","modified_gmt":"2025-08-30T13:29:55","slug":"rha_assessment_form","status":"publish","type":"page","link":"https:\/\/rockgardenehr.com\/blog\/rha_assessment_form\/","title":{"rendered":"CLIENT ASSESSMENT FORM"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1650\" class=\"elementor elementor-1650\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2b5b3279 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2b5b3279\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-37c879d\" data-id=\"37c879d\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-11e30a02 elementor-widget elementor-widget-shortcode\" data-id=\"11e30a02\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n  <div class=\"rha-form-header\">\n    <img decoding=\"async\" src=\"https:\/\/rockgardenehr.com\/rha-form-logo.png\" alt=\"Rockgarden Homecare Agency\" class=\"rha-logo\">\n    <h1 class=\"rha-title\">Client Assessment Form<\/h1>\n  <\/div>\n\n  <div class=\"rha-progress\" aria-hidden=\"true\"><div class=\"bar\" style=\"width:0%\"><\/div><\/div>\n\n  \n  <form id=\"rha-form\" method=\"post\" action=\"https:\/\/rockgardenehr.com\/blog2\/wp-admin\/admin-post.php\" class=\"rha-form-wrap\" novalidate>\n  <input type=\"hidden\" id=\"rha_nonce\" name=\"rha_nonce\" value=\"144e806672\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/blog\/wp-json\/wp\/v2\/pages\/1650\" \/>  <input type=\"hidden\" name=\"action\" value=\"rha_submit_assessment\">\n  <input type=\"hidden\" name=\"signatureData\" id=\"signatureData\">\n  <input type=\"text\" name=\"website\" style=\"display:none\" tabindex=\"-1\" autocomplete=\"off\">  <input type=\"hidden\" name=\"_r\" value=\"https:\/\/rockgardenehr.com\/blog\/rha_assessment_form\/\">\n\n  <!-- ===== Section A: Personal Details ===== -->\n  <section class=\"rha-step active\" data-step=\"1\">\n    <h2>Section A: Personal Details<\/h2>\n    <div class=\"subline\" aria-hidden=\"true\"><\/div>\n\n    <div class=\"grid\">\n      <label>Title <span class=\"req\">*<\/span>\n        <select name=\"title\" required>\n          <option value=\"\">Select\u2026<\/option>\n          <option>Mr.<\/option><option>Mrs.<\/option><option>Ms<\/option><option>Alhaji<\/option><option>Alhaja<\/option><option>Other<\/option>\n        <\/select>\n      <\/label>\n\n      <label>Full Name <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"client_name\" placeholder=\"Patron's full name\" required>\n      <\/label>\n\n      <label>Date of Birth <span class=\"req\">*<\/span>\n        <input type=\"date\" name=\"dob\" required>\n      <\/label>\n\n      <label>Age <span class=\"req\">*<\/span>\n        <input type=\"number\" name=\"age\" placeholder=\"Patron's Age\" min=\"0\" required>\n      <\/label>\n\n      <fieldset class=\"checks required\" style=\"grid-column: span 12;\">\n        <legend>Gender <span class=\"req\">*<\/span><\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"gender\" value=\"Male\" required> Male<\/label>\n          <label><input type=\"radio\" name=\"gender\" value=\"Female\"> Female<\/label>\n          <label><input type=\"radio\" name=\"gender\" value=\"Other\"> Others<\/label>\n        <\/div>\n        <div class=\"error-msg\" aria-live=\"polite\"><\/div>\n      <\/fieldset>\n\n      <fieldset class=\"checks required \" style=\"grid-column: span 12;\">\n        <legend>Marital Status <span class=\"req\">*<\/span><\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"marital_status\" value=\"Single\" required> Single<\/label>\n          <label><input type=\"radio\" name=\"marital_status\" value=\"Married\"> Married<\/label>\n          <label><input type=\"radio\" name=\"marital_status\" value=\"Widowed\"> Widowed<\/label>\n          <label><input type=\"radio\" name=\"marital_status\" value=\"Divorced\"> Divorced<\/label>\n        <\/div>\n        <div class=\"error-msg\" aria-live=\"polite\"><\/div>\n      <\/fieldset>\n\n      <label>State of Origin <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"state_of_origin\" placeholder=\"Patron's State of Origin\" required>\n      <\/label>\n\n      <label>Address <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"address\" placeholder=\"Patron's home address\" required>\n      <\/label>\n\n      <label>Phone Number(s) <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"phone\" placeholder=\"Patron's phone number\" required>\n      <\/label>\n\n      <label>Email Address\n        <input type=\"email\" name=\"email\" placeholder=\"add a valid email address\">\n      <\/label>\n\n      <label>Language(s) Spoken <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"languages\" required>\n      <\/label>\n\n      <label>Weight (kg) <span class=\"req\">*<\/span>\n        <input type=\"number\" step=\"0.1\" name=\"weight\" required>\n      <\/label>\n\n      <label>Height (cm)\n        <input type=\"number\" step=\"0.1\" name=\"height\">\n      <\/label>\n\n      <label>Are you receiving services from any other homecare agency? <span class=\"req\">*<\/span>\n        <select name=\"other_treatment_services\" required>\n          <option value=\"\">Select\u2026<\/option>\n          <option>Yes<\/option><option>No<\/option>\n        <\/select>\n      <\/label>\n    <\/div>\n\n    <div class=\"rha-actions\">\n      <button type=\"button\" class=\"rha-btn primary next\">Next<\/button>\n    <\/div>\n  <\/section>\n\n  <!-- ===== Section B: Medical History & Current Health ===== -->\n  <section class=\"rha-step\" data-step=\"2\">\n    <h2>Section B: Medical History & Current Health<\/h2>\n    <div class=\"subline\" aria-hidden=\"true\"><\/div>\n\n    <label>Primary Doctor \/ Clinic <span class=\"req\">*<\/span>\n      <input type=\"text\" name=\"primary_doctor\" required>\n    <\/label>\n\n    <label>Medical Conditions \/ Diagnoses <span class=\"req\">*<\/span>\n      <input type=\"text\" name=\"medical_conditions\" required>\n    <\/label>\n\n    <label>Past Medical History\n      <textarea name=\"other_conditions\" rows=\"2\"><\/textarea>\n    <\/label>\n\n    <label>Past Surgical History\n      <textarea name=\"surgeries\" rows=\"2\"><\/textarea>\n    <\/label>\n\n    <label>List of current medications with possible indications\n      <textarea name=\"medications\" rows=\"3\"><\/textarea>\n    <\/label>\n\n    <label>Allergies (food, drug, environmental)\n      <textarea name=\"allergies\" rows=\"3\"><\/textarea>\n    <\/label>\n\n    <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n      <legend>Mobility Status<\/legend>\n      <div class=\"checks-grid\">\n        <label><input type=\"radio\" name=\"mobility\" value=\"Independent\"> Independent<\/label>\n        <label><input type=\"radio\" name=\"mobility\" value=\"Uses Walking Aid\"> Uses Walking Aid<\/label>\n        <label><input type=\"radio\" name=\"mobility\" value=\"Wheelchair\"> Wheelchair<\/label>\n        <label><input type=\"radio\" name=\"mobility\" value=\"Bedridden\"> Bedridden<\/label>\n      <\/div>\n    <\/fieldset>\n\n    <label>Special Medical Equipment (oxygen, catheter, etc.)\n      <textarea name=\"medical_equipment\" rows=\"3\"><\/textarea>\n    <\/label>\n\n    <label>History of Urinary Incontinence\n      <select name=\"urinary_incontinence\"><option>Yes<\/option><option>No<\/option><\/select>\n    <\/label>\n\n    <label>History of Faecal Incontinence\n      <select name=\"faecal_incontinence\"><option>Yes<\/option><option>No<\/option><\/select>\n    <\/label>\n\n    <label>Number of Falls in Past 12 Months\n      <textarea name=\"falls\" rows=\"2\"><\/textarea>\n    <\/label>\n\n    <fieldset class=\"checks\" style=\"margin-top:10px\">\n      <legend>History of Chronic Illnesses (tick as applicable)<\/legend>\n      <div class=\"checks-grid\">\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Hypertension\"> Hypertension<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Diabetes\"> Diabetes<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Stroke\"> Stroke<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Arthritis\"> Arthritis<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Heart Disease\"> Heart Disease<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Kidney Disease\"> Kidney Disease<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Dementia\/Alzheimer\u2019s\"> Dementia\/Alzheimer\u2019s<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Cancer\"> Cancer<\/label>\n                  <label><input type=\"checkbox\" name=\"symptoms[]\" value=\"Respiratory Disease (Asthma, COPD)\"> Respiratory Disease (Asthma, COPD)<\/label>\n              <\/div>\n      <label>Others <input type=\"text\" name=\"others_illness\" placeholder=\"state other illnesses not listed\"><\/label>\n    <\/fieldset>\n\n    <div class=\"rha-actions\">\n      <button type=\"button\" class=\"rha-btn secondary prev\">Back<\/button>\n      <button type=\"button\" class=\"rha-btn primary next\">Next<\/button>\n    <\/div>\n  <\/section>\n\n  <!-- ===== Section C: Latest Investigations ===== -->\n  <section class=\"rha-step\" data-step=\"3\">\n    <h2>Section C: Latest Investigations<\/h2>\n    <div class=\"subline\" aria-hidden=\"true\"><\/div>\n\n    <div class=\"grid\">\n      <label>Latest Blood Pressure (mmHg) <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"blood_pressure\" required>\n      <\/label>\n\n      <label>Latest Fasting Blood Sugar (mg\/dl) <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"blood_sugar\" required>\n      <\/label>\n\n      <label>HIV Status <span class=\"req\">*<\/span>\n        <select name=\"hiv\" required>\n          <option value=\"\">Select\u2026<\/option>\n          <option>Positive<\/option><option>Negative<\/option><option>Not Done<\/option>\n        <\/select>\n      <\/label>\n\n      <label>HBsAg Status <span class=\"req\">*<\/span>\n        <select name=\"hbsag\" required>\n          <option value=\"\">Select\u2026<\/option>\n          <option>Positive<\/option><option>Negative<\/option><option>Not Done<\/option>\n        <\/select>\n      <\/label>\n\n      <label>HCV Status <span class=\"req\">*<\/span>\n        <select name=\"hcv\" required>\n          <option value=\"\">Select\u2026<\/option>\n          <option>Positive<\/option><option>Negative<\/option><option>Not Done<\/option>\n        <\/select>\n      <\/label>\n    <\/div>\n\n    <div class=\"rha-actions\">\n      <button type=\"button\" class=\"rha-btn secondary prev\">Back<\/button>\n      <button type=\"button\" class=\"rha-btn primary next\">Next<\/button>\n    <\/div>\n  <\/section>\n\n  <!-- ===== Section D: Care Needs ===== -->\n  <section class=\"rha-step\" data-step=\"4\">\n    <h2>Section D: Care Needs<\/h2>\n    <div class=\"subline\" aria-hidden=\"true\"><\/div>\n\n    <fieldset class=\"checks\">\n      <legend>Caregiver Support (tick all that apply)<\/legend>\n      <div class=\"checks-grid\">\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Personal Care (bathing, dressing, grooming)\"> Personal Care (bathing, dressing, grooming)<\/label>\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Medication Reminders\"> Medication Reminders<\/label>\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Meal Preparation &amp; Feeding Support\"> Meal Preparation &amp; Feeding Support<\/label>\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Mobility Support \/ Transfers\"> Mobility Support \/ Transfers<\/label>\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Continence Care (toileting, diaper change, etc.)\"> Continence Care (toileting, diaper change, etc.)<\/label>\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Companionship \/ Social Interaction\"> Companionship \/ Social Interaction<\/label>\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Light Housekeeping &amp; Errands\"> Light Housekeeping &amp; Errands<\/label>\n                  <label><input type=\"checkbox\" name=\"caregiver_support[]\" value=\"Escort to Appointments \/ Community Outings\"> Escort to Appointments \/ Community Outings<\/label>\n              <\/div>\n    <\/fieldset>\n\n    <fieldset class=\"checks\">\n      <legend>Registered Nurse (RN) Care (tick all that apply)<\/legend>\n      <div class=\"checks-grid\">\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Medication Administration \/ Injections\"> Medication Administration \/ Injections<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Wound Care &amp; Dressing Changes\"> Wound Care &amp; Dressing Changes<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Vital Signs Monitoring (BP, Temp, Pulse, etc.)\"> Vital Signs Monitoring (BP, Temp, Pulse, etc.)<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Chronic Disease Management (e.g., Diabetes, Hypertension)\"> Chronic Disease Management (e.g., Diabetes, Hypertension)<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Catheter Care \/ Stoma Care \/ Tracheostomy Care\"> Catheter Care \/ Stoma Care \/ Tracheostomy Care<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Tube Feeding (NG Tube, PEG)\"> Tube Feeding (NG Tube, PEG)<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Oxygen Therapy \/ Suctioning\"> Oxygen Therapy \/ Suctioning<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Post-Surgical Nursing Care\"> Post-Surgical Nursing Care<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"Pain Management\"> Pain Management<\/label>\n                  <label><input type=\"checkbox\" name=\"rn_care[]\" value=\"End-of-Life \/ Palliative Nursing\"> End-of-Life \/ Palliative Nursing<\/label>\n              <\/div>\n    <\/fieldset>\n\n    <fieldset class=\"checks\">\n      <legend>Physiotherapy Services (tick all that apply)<\/legend>\n      <div class=\"checks-grid\">\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Mobility &amp; Balance Training\"> Mobility &amp; Balance Training<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Strengthening &amp; Endurance Exercises\"> Strengthening &amp; Endurance Exercises<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Range of Motion Therapy\"> Range of Motion Therapy<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Stroke \/ Neurological Rehabilitation\"> Stroke \/ Neurological Rehabilitation<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Post-Surgical Rehabilitation (Hip\/Knee Replacement)\"> Post-Surgical Rehabilitation (Hip\/Knee Replacement)<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Pain Management Techniques\"> Pain Management Techniques<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Breathing &amp; Chest Physiotherapy\"> Breathing &amp; Chest Physiotherapy<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Fall Prevention Program\"> Fall Prevention Program<\/label>\n                  <label><input type=\"checkbox\" name=\"physio_services[]\" value=\"Assistive Device Training (walkers, canes, wheelchairs)\"> Assistive Device Training (walkers, canes, wheelchairs)<\/label>\n              <\/div>\n    <\/fieldset>\n\n    <div class=\"rha-actions\">\n      <button type=\"button\" class=\"rha-btn secondary prev\">Back<\/button>\n      <button type=\"button\" class=\"rha-btn primary next\">Next<\/button>\n    <\/div>\n  <\/section>\n\n  <!-- ===== Section E: Social & Lifestyle Information ===== -->\n  <section class=\"rha-step\" data-step=\"5\">\n    <h2>Section E: Social & Lifestyle Information<\/h2>\n    <div class=\"subline\" aria-hidden=\"true\"><\/div>\n\n    <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n      <legend>Living Arrangement<\/legend>\n      <div class=\"checks-grid\">\n        <label><input type=\"radio\" name=\"living_arrangement\" value=\"Lives Alone\"> Lives Alone<\/label>\n        <label><input type=\"radio\" name=\"living_arrangement\" value=\"With Spouse\"> With Spouse<\/label>\n        <label><input type=\"radio\" name=\"living_arrangement\" value=\"With Children\/Family\"> With Children\/Family<\/label>\n        <label><input type=\"radio\" name=\"living_arrangement\" value=\"With Caregiver\"> With Caregiver<\/label>\n      <\/div>\n      <label>Others <input type=\"text\" name=\"living_arrangement_other\" placeholder=\"state other living arrangement not listed\"><\/label>\n    <\/fieldset>\n\n    <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n      <legend>Accommodation Type<\/legend>\n      <div class=\"checks-grid\">\n        <label><input type=\"radio\" name=\"accommodation_type\" value=\"Private Residence\"> Private Residence<\/label>\n        <label><input type=\"radio\" name=\"accommodation_type\" value=\"Apartment \/ Flat\"> Apartment \/ Flat<\/label>\n        <label><input type=\"radio\" name=\"accommodation_type\" value=\"Shared Housing\"> Shared Housing<\/label>\n      <\/div>\n      <label>Others <input type=\"text\" name=\"other_accommodation\" placeholder=\"state other accommodation type not listed\"><\/label>\n    <\/fieldset>\n\n    <div class=\"grid\" style=\"margin-top:10px\">\n      <label style=\"grid-column: span 12;\"><strong>Daily Activities & Interests:<\/strong><\/label>\n      <label style=\"grid-column: span 12;\">Hobbies\/Leisure Activities<input type=\"text\" name=\"hobbies_leisure\"><\/label>\n      <label style=\"grid-column: span 12;\">Religious\/Spiritual Practices<input type=\"text\" name=\"religion\"><\/label>\n      <label style=\"grid-column: span 12;\">Social Activities (e.g., clubs, gatherings) <input type=\"text\" name=\"social_activities\"><\/label>\n\n      <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n        <legend>Dietary Habits<\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"diet\" value=\"Regular Diet\"> Regular Diet<\/label>\n          <label><input type=\"radio\" name=\"diet\" value=\"Vegetarian\"> Vegetarian<\/label>\n          <label><input type=\"radio\" name=\"diet\" value=\"Diabetic Diet\"> Diabetic Diet<\/label>\n          <label><input type=\"radio\" name=\"diet\" value=\"Low-Salt \/ Cardiac Diet\"> Low-Salt \/ Cardiac Diet<\/label>\n        <\/div>\n        <label>Others <input type=\"text\" name=\"other_diet\" placeholder=\"state other dietary habits not listed\"><\/label>\n      <\/fieldset>\n\n      <label style=\"grid-column: span 12;\"><strong>Smoking \/ Alcohol Use:<\/strong><\/label>\n\n      <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n        <legend>Smoking<\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"smoking\" value=\"Yes\"> Yes<\/label>\n          <label><input type=\"radio\" name=\"smoking\" value=\"No\"> No<\/label>\n        <\/div>\n        <label>If yes, how often? <input type=\"text\" name=\"smoking_frequency\"><\/label>\n      <\/fieldset>\n\n      <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n        <legend>Alcohol<\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"alcohol\" value=\"Yes\"> Yes<\/label>\n          <label><input type=\"radio\" name=\"alcohol\" value=\"No\"> No<\/label>\n        <\/div>\n        <label>If yes, how often? <input type=\"text\" name=\"alcohol_frequency\"><\/label>\n      <\/fieldset>\n\n      <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n        <legend>Sleep Pattern<\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"sleep_pattern\" value=\"Normal\"> Normal<\/label>\n          <label><input type=\"radio\" name=\"sleep_pattern\" value=\"Difficulty Falling Asleep\"> Difficulty Falling Asleep<\/label>\n          <label><input type=\"radio\" name=\"sleep_pattern\" value=\"Frequent Night Waking\"> Frequent Night Waking<\/label>\n          <label><input type=\"radio\" name=\"sleep_pattern\" value=\"Daytime Sleepiness\"> Daytime Sleepiness<\/label>\n        <\/div>\n        <label>Others <input type=\"text\" name=\"other_pattern\" placeholder=\"state other sleep patterns not listed\"><\/label>\n      <\/fieldset>\n\n      <label>Primary Family Contact\n        <input type=\"text\" name=\"primary_family\" placeholder=\"Name of primary family contact\">\n      <\/label>\n\n      <label>Frequency of Family Visits\n        <input type=\"text\" name=\"family_visit\">\n      <\/label>\n\n      <label>Community \/ Religious Support\n        <select name=\"community_support\"><option>Yes<\/option><option>No<\/option><\/select>\n      <\/label>\n    <\/div>\n\n    <div class=\"rha-actions\">\n      <button type=\"button\" class=\"rha-btn secondary prev\">Back<\/button>\n      <button type=\"button\" class=\"rha-btn primary next\">Next<\/button>\n    <\/div>\n  <\/section>\n\n  <!-- ===== Section F: Risk Assessment ===== -->\n  <section class=\"rha-step\" data-step=\"6\">\n    <h2>Section F: Risk Assessment<\/h2>\n    <div class=\"subline\" aria-hidden=\"true\"><\/div>\n\n    <div class=\"grid\">\n      <label>Falls Risk\n        <select name=\"falls_risk\"><option>Low<\/option><option>Medium<\/option><option>High<\/option><\/select>\n      <\/label>\n\n      <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n        <legend>Cognitive Status<\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"cognitive\" value=\"Alert & Oriented\"> Alert & Oriented<\/label>\n          <label><input type=\"radio\" name=\"cognitive\" value=\"Mild Memory Loss\"> Mild Memory Loss<\/label>\n          <label><input type=\"radio\" name=\"cognitive\" value=\"Dementia\"> Dementia<\/label>\n          <label><input type=\"radio\" name=\"cognitive\" value=\"Confused\"> Confused<\/label>\n        <\/div>\n      <\/fieldset>\n\n      <label style=\"grid-column: span 12;\">Behavioral Concerns (aggression, wandering, depression, etc.)\n        <textarea name=\"behavioral_concerns\" rows=\"2\"><\/textarea>\n      <\/label>\n\n      <fieldset class=\"checks\" style=\"grid-column: span 12;\">\n        <legend>Home Environment Safety<\/legend>\n        <div class=\"checks-grid\">\n          <label><input type=\"radio\" name=\"home_environment\" value=\"Safe\"> Safe<\/label>\n          <label><input type=\"radio\" name=\"home_environment\" value=\"Potential Hazards\"> Potential Hazards<\/label>\n        <\/div>\n      <\/fieldset>\n\n      <label style=\"grid-column: span 12;\">If hazards, specify\n        <input type=\"text\" name=\"other_hazards\">\n      <\/label>\n    <\/div>\n\n    <div class=\"rha-actions\">\n      <button type=\"button\" class=\"rha-btn secondary prev\">Back<\/button>\n      <button type=\"button\" class=\"rha-btn primary next\">Next<\/button>\n    <\/div>\n  <\/section>\n\n  <!-- ===== Section G: Consent & Agreement ===== -->\n  <section class=\"rha-step\" data-step=\"7\">\n    <h2>Section G: Consent & Agreement<\/h2>\n    <div class=\"subline\" aria-hidden=\"true\"><\/div>\n\n    <p class=\"muted\">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.<\/p>\n\n    <div class=\"grid\">\n      <label style=\"grid-column: span 12;\">Name (Person\/Institution Responsible for Payment) <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"payer_name\" required>\n      <\/label>\n\n      <label>Relationship with Client <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"payer_relationship\" required>\n      <\/label>\n\n      <label>Phone Number of Above <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"payer_phone\" required>\n      <\/label>\n\n      <label style=\"grid-column: span 12;\">Client Next of Kin's Name <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"nok_name\" required>\n      <\/label>\n\n      <label style=\"grid-column: span 12;\">Client Next of Kin's Address <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"nok_address\" required>\n      <\/label>\n\n      <label>Client Next of Kin's Phone Number <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"nok_phone\" required>\n      <\/label>\n\n      <label>Client Next of Kin's Email\n        <input type=\"email\" name=\"nok_email\">\n      <\/label>\n\n      <label>Signatory's Full Name <span class=\"req\">*<\/span>\n        <input type=\"text\" name=\"signature_name\" required>\n      <\/label>\n\n      <label>Date <span class=\"req\">*<\/span>\n        <input type=\"date\" name=\"signature_date\" required>\n      <\/label>\n    <\/div>\n\n    <div class=\"sig-wrap\">\n      <label for=\"signature-pad\" class=\"sr-only\">Signature<\/label>\n      <div class=\"signature-hint\">Kindly use your fingers or a stylus pen to write your signature <span class=\"req\">*<\/span><\/div>\n      <canvas id=\"signature-pad\" width=\"600\" height=\"100\"><\/canvas>\n      <input type=\"hidden\" name=\"signatureData\" id=\"signatureData\">\n      <button id=\"clear\" class=\"rha-btn secondary\" type=\"button\">Clear<\/button>\n    <\/div>\n\n    <div class=\"rha-actions\">\n      <button type=\"button\" class=\"rha-btn secondary prev\">Back<\/button>\n      <button type=\"submit\" class=\"rha-btn primary\">Submit<\/button>\n    <\/div>\n  <\/section>\n<\/form>\n  <\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"yes","footnotes":""},"class_list":["post-1650","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/pages\/1650","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/comments?post=1650"}],"version-history":[{"count":22,"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/pages\/1650\/revisions"}],"predecessor-version":[{"id":18661,"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/pages\/1650\/revisions\/18661"}],"wp:attachment":[{"href":"https:\/\/rockgardenehr.com\/blog\/wp-json\/wp\/v2\/media?parent=1650"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}