Ability Homecare

Step 1 of 13

Contact Information

Client Information

Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Title

Career/Occupation

Race(Required)

Gender(Required)

Religion

Hair Color(Required)

Eye Color(Required)

Any Distinguishing Features

Home Phone Number

Cell Phone Number(Required)

Street Address(Required)

Apt/Condo #(Required)

City(Required)

State(Required)

Zip Code(Required)

Martial Status(Required)

Living Situation(Required)

If Other Please Explain

Does Client Smoke(Required)

Yes

Does Client Smoke(Required)

Cigarettes

Medicinal Marijuana

Vapor

Tabaco

Alcohol Consumption(Required)

Never

Rarely

Occasionally

Frequently

Comments

Advance Directive

Ability Homecare will comply with our client’s health care advance directives to the fullest extent possible, consistent with reasonable medical practice and applicable state laws. If our agency is not capable of complying with the client’s health care advance directives, Ability Homecare will notify the client and/or his/her legal representative when such fact becomes known. Ability Homecare does not require clients to have an executed health care advance directive as a condition of receiving home health services.

Does the client have an executed Health Care Advance Directive?(Required)

Yes

Does the client have a Power of Attorney?(Required)

Yes

Upload a Copy of Your Executed Health Care Advance Directive

Drop files here or

Max. file size: 128 MB.

Upload a Copy of Your Power of Attorney

Drop files here or

Max. file size: 128 MB.

Emergency Contact Information

Emergency Contact 1:(Required)

First Last

Relationship(Required)

Phone Number(Required)

Street Address(Required)

Apt/Condo #(Required)

City(Required)

State(Required)

Zip Code(Required)

Emergency Contact 2:

First Last

Relationship

Phone Number

Street Address

Apt/Condo #

City

State

Zip Code

Comments

Evacuation Assistance

Ability Homecare identifies clients who may need assistance with evacuation during an emergency and/or assistance with making evacuation arrangements.

Does the client have a plan in place for evacuation or sheltering in place?(Required)

Yes

Where does the client plan to stay during an emergency?(Required)

At Home

With Family

With Friend

Shelter

Other

If other please explain(Required)

Would you like to register with the transportation assistance registry?(Required)

Yes

If evacuation is required and client answered "No" to transportation assistance, how will client get to their evacuation location?(Required)

Does the client require medical assistance at the shelter?(Required)

Yes

Would you like to register with the special needs shelter?(Required)

Yes

Does the client require electrical power for their medical equipment at the shelter?(Required)

Yes

Comments

Health Information

Do not leave blank - write "n/a" for non-applicable

Height(Required)

Weight(Required)

Primary Language(Required)

Primary Diagnosis(Required)

Please List Any Other Diagnosis(Required)

Diabetes Care(Required)

Special Skin Care Precautions(Required)

Bed Sore(s) (Decubitus Ulcers) and location(Required)

Stages of Dementia(Required)

Mild Cognitive

Impairment

Mild Dementia

Severe

N/A

Observation(s)

Stages of Alzheimer's disease(Required)

Early Stage (mild)

Middle Stage (moderate)

Late Stage (severe)

N/A

Observation(s)

History of Falls / Safety Issues(Required)

Paralysis(Required)

Full

Partial

Local

N/A

Site

Prosthetic Devices(Required)

Hand

Arm

Leg

N/A

Specifics

Oxygen Therapy(Required)

Allergies(Required)

Comments

Communication

Ability to Hear(Required)

No impairment

Impairment evident but does not interfere with everyday functioning

Impairment interferes with everyday functioning

Hears with device

Ability to See(Required)

No impairment

Impairment evident but does not interfere with everyday functioning

Impairment interferes with everyday functioning, Sees with opticals

Understanding Instruction and What is Said(Required)

No impairment

Impairment evident but does not interfere with everyday communication

Impairment interferes with everyday communication or is significant enough to require the use of an alternate mode of communication

Minimal communication ability with or without the use of an alternative mode of communication

No communication ability

Memory(Required)

No impairment

Memory Impairment but does not interfere with everyday functioning

Memory impairment interferes with everyday functioning

Minimal or no memory functioning

Comments

Physician & Home Health Agency Information

Primary Care Physician(Required)

Name

Phone Number(Required)

Primary Care Physician Address

Street Address Suite # City State ZIP Code

Specialist

Name

Speciality

Phone Number

Specialist Address

Street Address Suite # City State ZIP Code

Do you have a home health agency for skilled care?(Required)

Yes

Name of Home Health Agency(Required)

Home Health Phone Number(Required)

Financial Information

Financial Class(Required)

Aetna Medicaid

Children's Medical Services

Humana Medicaid

Long-term Care Insurance

Private Pay

Staywell Medicaid

Sunshine Health

Other

Guarantor Name(Required)

First Last

Guarantor Phone Number(Required)

Case Manager(Required)

Name

Case Manager's Phone Number(Required)

Care Plan

Please provide the information where the initial evaluation will be completed.

Please select where the initial home care assessment will be conducted:(Required)

If Other, Please Provide Specifics

Address(Required)

Street Address Apt/Condo # City State ZIP Code

Contact Person(Required)

First Last

Relationship(Required)

Contact Person Phone Number 1(Required)

Contact Person Phone Number 2(Required)

Type of Care(Required)

Bath Visit

Hourly Care

24/7 Care

Live-in Care

Respite Care

Start Date(Required)

Month

Day

Year

Please help us get to know the care recipients interests.

Hobbies / Interest

Games / Puzzles

Social Gatherings

Favorite Television Shows

Passive / Active Sports

Outdoor Activities

Arts / Crafts

Outings / Excursions

Activities of Daily Living (ADL)

Assistance with feeding(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Assistance with range of motion exercises(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Assistance with bathing(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Bladder Incontinence(Required)

Constant

Frequent

Occasional

Rare

What Type of Catheter Do You Have?(Required)

Assistance with dressing(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Bowel Incontinence(Required)

Constant

Frequent

Occasional

Rare

What Type of Catheter Do You Have?(Required)

Assistance with grooming(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Assistance with mobility(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Assistance with tolieting(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Mobility Aids(Required)

None

Walker

Cane

Wheelchair

Motorized Wheelchair

Braces / Prostheses

Other

Assistance with ambulating / walking(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Assistance with transferring(Required)

Independent

Needs Supervision

Needs Assistance

Needs Total Help

Uses Assistive Device Hoyer Lift(Required)

Yes

Please list the device/equipment:(Required)

Assistance with self-administered Medications(Required)

Independent

Needs Supervision

Needs Assistance

Uses Assistive Technology(Required)

Yes

Please list the technology:

Please complete Medication Profile Form and Consent For Assistance with Self-administered Medication Form.

Repositioning(Required)

As Needed

Every 2-hours

Other

Uses Assistive Device(Required)

Yes

Please list the device/equipment:(Required)

Comments/ Special Instructions for Performing Assistance with ADLs

Instrumental Activities of Daily Living (IADL)

Companionship / Moral Support(Required)

Sociable

Non-sociable

Comments

Diet Instructions(Required)

Regular

Diabetic

No Added Salt

Low/Fat

Other

Comments

Meal Preparation(Required)

Breakfast

Lunch

Dinner

Snack

All

Comments

Medication Reminders(Required)

Yes

Comments

Tidying Up Kitchen(Required)

Yes

Comments

Tidying Up Bedroom(Required)

Yes

Comments

Tidying Up Bathroom(Required)

Yes

Comments

Tidying Up Living Room(Required)

Yes

Comments

Light Dusting Client's Furniture(Required)

Yes

Comments

Passing The Vacuum in Rooms Used by The Client(Required)

Yes

Comments

Spot Mopping the Floor(Required)

Yes

Comments

Personal Laundry Care(Required)

Yes

Comments

Shopping / Running Errands(Required)

Yes

Comments

Escorting Client To / From Appointments(Required)

Yes

Comments

Securing and Using Transportation(Required)

Yes

Comments

Using Telephone(Required)

Yes

Comments

Making / Keeping Appointments(Required)

Yes

Comments

Writing Correspondence(Required)

Yes

Comments

Comments/Instructions for Assistance with ADLs

Pet Care Assistance(Required)

Yes

Type of Pet(Required)

Cat

Dog

Other

Breed(Required)

How Many Pets(Required)

Pet Care Instructions(Required)

Person Completing Form:

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Home Care Assessment

Home Care Assessment

Contact Information

Advance Directive

Emergency Contact Information

Evacuation Assistance

Health Information

Communication

Physician & Home Health Agency Information

Financial Information

Care Plan

Activities of Daily Living (ADL)

Instrumental Activities of Daily Living (IADL)

Person Completing Form: