Patient Intake Assistance

New Patient Intake & Assessment Checklist

Employee Application Form

For Nurse/Administrator Use Only

Personal Information

Full Name:

Address:

Phone Number:

Email Address

Date of Birth:

Social Security Number:

Free Text

Employment Eligibility

Are you legally authorized to work in the United States?

Yes

No

Will you now or in the future require sponsorship for employment visa status?

Yes

No

Position Applied For

Certified Home Health Aide (CHHA)

Other:

Free Text

Certification and Training

CHHA Certification Number:

Issuing State:

Expiration Date:

Have you completed a NJ Board of Nursing-approved homemaker-home health aide training program?

Yes

No

If yes, Program Name:Past Surgeries/Hospitalizations:

Completion Date:

CPR Certification:

Yes

No

Issuing Organization:

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:

An Angel for Everyone LLC

Contact Information

Business Hours