Questionnaire for Clients
Intake Questionnaire

questionnaire.seniorcaremanhattan.com
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Please note: this is an online agreement and so please do not print this out, please just fill it out online and then click Submit at the end
If you have any questions, call us at 212-614-8057
Thank you!
Home Instead Senior Care
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  • We only cover Manhattan
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  • ACTIVITIES OF DAILY LIVING

    If you could provide a detail of items that you would like for the aide to do during the shift, please do so in each section below as this would help us enormously
  • Please specify if there is a next of kin, family member or legal guardian involved with decision making
  • 1) Are the medications in bottles or pill organizers?
    2) Can the client manage the meds alone or do they need assistance?
  • Please include all info that would be helpful
  • Please include any special instructions
  • 1) Can the client walk unassisted or does s/he need help?
    2) What equipment (cane, wheelchair) is used?
    3) Is the client a fall risk?
  • Please include any special instructions
  • Please include all activities you would like to see done
  • Please include any special instructions
  • Please let us know if you would like the caregiver to wear her uniform or not. If you have any other requests or instructions regarding the caregiver, please include them here.
  • Please include any special instructions
  • Please include any special instructions
  • So we can refer to medicare providers in the area of Physicians, Physical Therapy, Podiatrists and even equipment
  • Please include any special instructions