Client Assessment Form
Potential Client:		Current Living Arrangement:
Reason for Moving:		Language(s) Spoken and Understood:
Diagnosis		Willingness to Share Health Information:	Yes No
Medical		Other Support Services/Community Programs involving client:
Psychiatric		Allergies
Medically Stable:		Cultural Practices that may impact the normal operations of the home:
Seizure Activity:		Availability of an Advocate:
Any Hospitalization in the Past 12 months?		Other Factors:
Contact Name:		Phone number:	() -
Email:		Age: (optional)
Gender: (optional)	OptionalMaleFemale	Weight: (optional)
Smoking: No Yes Pet: No Yes Alcohol Use: No Yes Supplemental Oxygen: No Yes Vision: Good/with Correction Vision Poor Legally Blind Hearing: Normal Wears hearing aid Profoundly deaf Dental: Has own teeth Wears dentures Has no teeth Diet/Hydration: Independent Assistance Total Assistance Diet: Normal Low sugar/low salt Complex needs Elimination Bladder: Independent Assistance Total Assistance Elimination Bowel: Independent Assistance Total Assistance Incontinence Bladdder: Independently Managed Assistance Total Assistance Incontinence Bowel: Independently Managed Assistance Total Assistance Mobility: Independent Assistance Total Assistance required Mobility Equipment: Independent Assistance Heavy Equipment (mechanical Lift/wheelchair) Medication Administration: Independent Assistance Total Assistance Care Procedures: (injections,dressing changes, urinary catheter) Independent Assistance Care Transfers: Independent Assistance Care Supervision: Independent Minimal supervision/Asleep staff 24 hr awake staff required Pain Management: Independent Assistance Care Memory: Good Short term loss Short/long term loss Communication: Verbal Non-verbal Behaviour Issues: Physical Aggression: No concern Minimal concern significant concern Verbal Aggression: No concern Minimal concern significant concern Withdrawn/prefers to be alone: No concern Minimal concern significant concern Hyperactive/restlessness: No concern Minimal concern significant concern Elopment risk: No concern Minimal concern significant concern Rummaging/hoarding: No concern Minimal concern significant concern Interactions with others: Cooperative/friendly Non-participatory/Withdrawn Resentful/unfriendly Home Management Skills: (personal laundry, room housekeeping) Independent Assistance Total Assistance Activities of Daily Living: Independent Assistance Total Assistance Money Management: Independent Assistance Total Assistance Transportation: Independent Assistance Total Assistance/Accompaniment Arranging Appointments: Independent Assistance Total Assistance Safety Issues: Choking Risk: No risk Some risk High risk Risk of Falling: No risk Some risk High risk Ability to evacuate home: Independent Assistance Total Assistance Ability to access home: Independent Assistance Total Assistance