* = Required Information
List the Primary Contacts
Appointments
Billing
Emergencies
Needing Placement
Information about the Care Recipient
Cane
Walker
Wheelchair
Electric Stair Lift
Electric Cart
Bedside Commode
Oxygen Equipment
CPAP Machine
Hospital Bed
Hoyer Lift
Shower Bench/Chair
Reacher
Raised Toilet Seat
Transfer Board
Prosthesis


Normal
Diabetic
Low Sodium
Liquid Only
Activities of Daily Living
Amputation
Incontinence
Contracture
Hearing
Paralysis
Endurance
Ambulation
Speech
Legally Blind
Dyspnea with Minimal Exertion
Other Specify
Complete Bed Rest
Bed Rest BRP
Up as Tolerated
Transfer Bed/Chair
Exercises Prescribed
Partial Weight Bearing
Independent at Home
No Restrictions
Oriented
Comatose
Forgetful
Depressed
Disoriented
Lethargic
Agitated
Assist Ambulation
Assist Transfers
Assist Bed/Chair Only
Assist ROM Exercises
Bedridden
Can turn on water fixtures
Can regulate water temperature
Can get safely in and out of bath or shower
Uses soap and washcloth
Washes hair on own
Drys off without assistance
Manages on own
Urgency issues / timely
Hard to rise
Unable to properly clean afterwards
Difficulty with clothes
Right Eye
Lefgt Eye
Peripheral Only
Wears Glasses
Clean Glasses
Assist with Meal Preparation
Assist in Feeding
Trouble Chewing
Trouble Swallowing
Feeds Self
Moisturizers
Powder
Skin Issues
Self dresses
Help Select Clothes
Assist with Dressing
Instrumental Activities of Daily Living
Can they collect dirty clothes for washing
Can they sort clothes properly
Can access laundry facilities
Can they load and unload clothes
Can they handle soap, bleach, etc..
Can they move to washer to dryer and hang
Can They put away clothes ok
Can they prepare own meals
Can they plan well-balanced meals
Can they safely operate kitchen utensils and appliances
Can they reach dishes, pots and pans, needed
Can they carry foods to the table
Can they clean vegetables and fruits, chop foods, etc..
Can they navigate within a shopping facility
Can they lift things from shelves
Can they effectively handle money
Can they store purchases appropriately
Can they carry purchases from store to car and home
Care Recipient's Car
Caregivers's Car
Other
Can they effectively budget money
Are they able to write checks
Can they pay bills on time
Do you think they are being finacially exploited
One Story
Multi-Level
Smoker
Pets
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