EmailMe Form - Questionnaire for Clients

Name of person filling this out *
Name of Senior who would receive services *
Email of person filling this out *
Today's Date *
MM / DD / YYYY
How did you hear about us: *
Your relationship to Client *
Address of the senior (or area in Manhattan) *
We only cover Manhattan
Telephone # of the senior *
Date of Birth *
MM / DD / YYYY
Age of Senior *
Approx height *
Approx weight *
Does the senior live alone or with someone? *
Are there any pets in the home?
Please describe (i) type of pet (ii) size (iii) is there any expectation of us providing any care for this pet (as this may require an additional fee).
I. COVID-19 (Coronavirus) - 3 questions
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COVID-19 Intake Screening - please note that we need to follow specific NYS Department of Health protocols before taking any cases

Please check off any and all that apply *
(*) Senior (nor anyone living with Senior) does not (did not have) a diagnosis of COVID-19 (or suspected COVID-19)
(*) Senior (nor anyone living with Senior) did not recently travel to any of the following countries: China, Iran, South Korea, Italy, Spain or Japan
(*) Senior (nor anyone living with Senior) has not had contact with anyone with confirmed COVID-19 (or suspected COVID-19) in the last 14 days
(*) Senior (nor anyone living with Senior) does not have Fever greater than 100
(*) Senior (nor anyone living with Senior) does not have Difficulty breathing
(*) Senior (nor anyone living with Senior) does not have Cough
COVID-19 Vaccine - Click here for instructions how to get vaccine (& booster) in NYC
I clicked the link provided and I am aware that Senior is eligible to receive a vaccine immediately and that Home Instead recommends that this be discussed with Senior's primary care physician immediately
COVID-19 Vaccine - choose at least 1 *
(*) Senior is fully vaccinated against COVID-19 (but not the booster)
(*) Senior has received (i) the full COVID vaccine and (ii) one booster
(*) Senior has received (i) the full COVID vaccine and (ii) two boosters
(*) Senior has received (i) the full COVID vaccine and (iii) three boosters
(*) Senior is imminently planning to receive the COVID vaccine soon
(*) Senior is eventually planning to receive the COVID vaccine
(*) Senior is NOT interested in receiving the COVID vaccine anytime soon but realizes s/he is eligible to get one in NYC immediately
Other
II. BASIC HEALTH INFO
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Basic Medical History/ List of condition(s)/ diagnosis *
Is Senior currently at a hospital/rehab center about to be discharged home? *
If currently hospitalized, please provide reason for admission and location.
Special Situation(s) - Please check off any that apply *
(*) NOTHING ON THIS LIST BELOW APPLIES
(*) Senior has 1 or more wounds that require attention (please note there are restrictions as to how a Home Instead caregiver can help and this may require assistance from VNS)
(*) Senior has a catheter or ostomy ( please note there are restrictions as to how a Home Instead caregiver can help)
(*) Senior is diabetic and requires assistance with insulin management (please note that Home Instead caregivers canNOT do finger sticks or inject insulin)
(*) Senior has a PEG or other type of feeding tube (Home Instead caregivers canNOT assist in this type of feeding)
(*) Senior is combative
(*) Senior is on hospice or is critically ill
Hearing *
Speech *
Vision *
Swallowing *
Schedule: the desired schedule would be the following *
(*) Overnight Hours (12 hours overnight)
(*) Two 12 hour shifts (one day shift and a separate night shift; charged at the hourly rate x 24 hours)
(*) Live-in rate (1 person doing 24 hours straight and sleeping in the home for multiple days
(*) Daytime Hours only (please specify hours and days). Please note that our minimum hours per day are 5 hours Mondays to Fridays, and 8 hours Saturdays and Sundays.
When would you like to commence services (date please) *
III. MEDICATIONS SECTION
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Client currently takes medications *
If Medications are pre-filled in organized trays, please state the name of the person in charge of doing so.
Medication tray (see image below) *
MEDICATION REMINDERS
Client needs the following assistance re medications from the Home Instead caregiver *
Simple Medication reminders from a Home Health Aide
No assistance needed at all
Other
IV. COGNITIVE FUNCTION
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Mental/ cognitive status (Choose 1) *
Name of Person who will assist with decisions *
Please specify if there is a next of kin, family member or legal guardian involved with decision making.
V. ACTIVITIES OF DAILY LIVING
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Ability to walk (ambulation) is as follows *
Ambulation concerns
1) If the client needs help, please provide details.
2) What equipment (cane, wheelchair) is used?
3) Is the client a fall risk?
Meal Preparation
Please include all info that would be helpful
Meals, Fluid or diet preference/ restrictions
Please include any special instructions
Bathing/ Toileting instructions
Please include any special instructions
Activities/ hobbies
Please include all activities you would like to see done.
VI. OTHER
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Caregiver's Uniform / Other *
Please let us know if you would like the caregiver to wear a uniform or not (we encourage this for reasons of hygiene, safety and professionalism). If you have any other requests or instructions regarding the caregiver, please include them here.
Overnight Services
If you are requesting overnight services, please let us know if
1) the senior has any specific needs at night to be aware of (example - Senior is a wandering risk etc),
2) where should we instruct the caregiver to be during the shift (bedside, living room, etc).
What are the top 5 concerns we should be aware of (if any)
Please include any special instructions, behavioral issues, etc.
Service Agreement *
Medicare # (if available)
So we can refer to medicare providers in the area of Physicians, Physical Therapy, Podiatrists and even equipment.
Doctors - names and phone #s of Primary Care Physician and specialists
Please include any special instructions.
Emergency Contacts (list names, relationship and phone #s - in order of importance)
Please include any special instructions.
Other Notes: please add anything else that would be helpful for us to know (ie: any specific instructions, allergies, or if there is a smoker in the home).
Please note that the information provided above will be reviewed with you during our Nurse's initial visit or Care Consult.
Any care plan related questions? Call us at 212-614-8054 or email us at bal@homeinsteadny.com *