Your Name:

Address:

Phone:

E-mail:

Who is this assessment for:

Name:

Address:

Phone:

Date of Birth:

Sex:

Please Select Female Male

Marital Status:

Please Select Married Single Divorced Widowed

Relationship:

With whom does he/she live:

Please Select Spouse Family Alone Other

How tall is he/she:

How much does he/she weigh:

Does he/she use a hearing aid:

Yes No

Does he/she use a hospital bed:

Yes No

Does he/she us an oxygen equipment:

Yes No

What is his/her medical condition:

Bathing

Difficulty bathing unassisted

Getting into tub Standing
Limited range of motion

Other

Dressing

Difficulty dressing unassisted

Assistance from another person
Minor assistance using a grab bar
Other

Toileting

Difficulty using the toilet unassisted

Assistance from another person
Minor assistance using special equipment
Commode Diaper

Other

Transferring

Ability to transfer to and from bed, chair or wheelchair:

Please Select Independent Minimal Assistance Moderate Assistance Total Assistance

Difficulty transferring unassisted

Assistance from another person
Mechanical assistance Minor assistance using adaptive or assistive device

Other

Ambulating

Difficulty walking unassisted

Assistance from another person
Mechanical assistance Minor assistance using a cane or walker

Other

Eating

How many meals does he/she eat a day:

Please Select 1 2 3 4 or More

Difficulties while eating:

Chewing Swallowing
Cutting

Other

Medications

Any help managing medications:

Assisted by family or friends Agency assistance Pillbox

Other

Grocery Shopping

How he/she goes for shopping

Drives Family, friend or neighbor drives Walks
Public transportation Shuttle service
Other

Meal Preparation

How does he/she prepare meals:

Alone Family Meals on wheels
Other

Housework

Ability to perform basic housework:

Please Select Independent Minimal Assistance Moderate Assistance Total Assistance

Psychosocial

Psychosocial Information

How soon you need a caregiver?

How soon you need a caregiver?

Please Select Soon as Possible One Week from Today Two Weeks from Today A Month from Today

Hours par day you need a caregiver?

Minimum 4 hours par day please!

Monday Hrs

Tuesday Hrs

Wednesday Hrs

Thursday Hrs

Friday Hrs

Saturday Hrs

Sunday Hrs

How did you hear about our services?

How did you hear about our services?

Please Choose Trade Show Direct Mail Press Release Referral Internet Telephone Solicitation Email Advertisement Other

Do you have any pets and how many?

If you have any pets, please enter it here.

Pets

Date:

Independent Contractor vs. Employee IRS

How are you going to pay - directly or trough Smile & Love Inc?

Payment Options Smile and Love Inc Employee Independent Contractor Long Term Care Insurance