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Are You Ready to Begin Your Journey to best Home Care?

Simply follow these nine simple steps to complete your loved one's profile, and we'll get you started.

Client Information

Full Name

Date of birth

Gender

Contact Number

Email Address

Address

Emergency Contact Information

Emergency Contact Name

Relationship to Client

Contact Number

Email Address

Medical Information

Primary Care Physician

Physician's Contact Number

Health Insurance Provider

Policy Number

Any Known Allergies

Living Arrangements

Q. Is the client living alone or with others?

Living Alone

Living with others / specify

Q. Are there any specific cultural or religious considerations that need to be taken into account?

Yes / specify

Q. Are there any pets in the household?

Yes / specify

Services Requested

Our Services

Please check the services the client requires assistance with:

Light Housekeeping

Companionship

Meal Preparation, Planning, and Baking

Personal Hygiene and Grooming

Monitoring client safety

Attending meetings and religious services

Walks in the neighborhood

24-hour live-in support

Daily errands

Doctor’s appointments

Respite

Leisurely drive

Health and Mobility

Q. Are there any specific health conditions or diagnoses?

Yes / specify

Q. Is the client experiencing any mobility limitations?

Yes / specify

Q. Does the client require assistive devices (e.g., wheelchair, walker)?

Yes / specify

Q. Is there a history of falls or accidents?

Yes / specify

Medication Management

Q. Is the client currently taking any medications?

Yes / specify

Q. Is the client currently taking any medications?

Yes

Special Dietary Needs

Q. Does the client have any dietary restrictions or preferences?

Yes / specify

Q. Are there any specific food allergies or intolerance?

Yes / specify

Additional Information

Q. Are there any specific hobbies, interests, or activities that the client enjoys?

Yes / specify

Q. Are there any cultural or language preferences that need to be considered?

Yes / specify

Q. Are there any specific communication or language barriers that need to be addressed?

Yes / specify