Patient Intake Assistance

New Patient Intake & Assessment Checklist

New Patient Intake & Assessment Checklist

For Nurse/Administrator Use Only

1. Patient Information

1. Patient Information

Full Name:

Date of Birth:

Address:

Phone Number:

Primary Language:

Emergency Contact Name:

Relationship:

Emergency Contact Phone:

Primary Care Physician Name:

Physician Phone:

2. Medical History

2. Medical History

Current Medical Conditions:

Past Surgeries/Hospitalizations:

Known Allergies (medications, food, environmental):

Current Medications (name, dose, frequency):

3. Functional Assessment

3. Functional Assessment

Mobility Status:

Independent

Needs Assistance

Wheelchair-bound

Bedbound

Activities of Daily Living (ADLs):

Bathing:

Independent

Assistance Needed

Dressing:

Independent

Assistance Needed

Grooming:

Independent

Assistance Needed

Toileting:

Independent

Assistance Needed

Eating:

Independent

Assistance Needed

Instrumental Activities of Daily Living (IADLs):

Meal Preparation

Medication Management

Light Housekeeping

Transportation

4. Cognitive & Mental Health Status

4. Cognitive & Mental Health Status

Mental Health:

Depression

Anxiety

Other:

Communication:

Verbal

Non-verbal

Hearing Impaired

Speech Difficulty

5. Social History

5. Social History

Living Situation:

Alone

With Family

Assisted Living

Support System:

Family

Friends

Community Programs

Hobbies/Interests:

6. Nutritional Needs

6. Nutritional Needs

Dietary Restrictions:

New Field:

Regular Diet

Diabetic

Renal

Vegetarian/Vegan

Notable Concerns (weight loss, poor appetite, etc.):

7. Safety Assessment

7. Safety Assessment

Fall Risk:

Low

Moderate

High

Home Safety Hazards Noted:

8. Care Plan Goals

8. Care Plan Goals

Short-Term Goals (1-4 weeks):

Long-Term Goals (1+ months):

9. Care Coordination

9. Care Coordination

New Field:

PT/OT Referral Needed

Schedule for Aide Visits:

Time:

From

to

Family Communication Plan in Place

Notes:

Nurse/Administrator Notes

Completed By:

Date:

Start Your Personalized Home Care Intake Process

Contact Information

Business Hours