EmailMeForm
Questionnaire for Clients
Intake Questionnaire
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Please note: this is an online questionnaire and so please do not print this out, please just fill it out online (as much as you can) and then click Submit at the end
If you have any questions, call us at 212-614-8057
Thank you!
Home Instead
Name of person filling this out
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Name of Senior who would receive services
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Email of person filling this out
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Today's Date
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MM
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How did you hear about us:
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Your relationship to Client
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Please select
I am the Client
I am a family member authorized to represent Client
I am a friend authorized to represent Client
I am the Health Care Proxy for the Senior
I am a Caregiver for the client
I work for/with the Client
Other
Address of the senior (or area in Manhattan)
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We only cover Manhattan
Telephone # of the senior
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Date of Birth
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MM
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Age of Senior
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Approx height
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Approx weight
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Does the senior live alone or with someone?
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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
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(*) 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
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(*) 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
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Is Senior currently at a hospital/rehab center about to be discharged home?
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If currently hospitalized, please provide reason for admission and location.
Special Situation(s) - Please check off any that apply
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(*) 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
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Please select
Good
Poor
Deaf
Speech
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Please select
Good
Poor
Not able to speak
Vision
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Please select
Good
Poor
Blind
Swallowing
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Please select
Good
Poor
Problems swallowing (aspiration risk)
Not able to swallow (feeding by PEG or TPN)
Schedule: the desired schedule would be the following
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(*) 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)
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III. MEDICATIONS SECTION
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Client currently takes medications
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Please select 1
Directly from the pill bottles (Client has capacity to do this)
Directly from the pill organizers (labeled Sun, Mon, Tues, Wed, Thurs, Fri and Sat)
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)
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Please select 1
I would like for a Registered Nurse to come 1-2 times a month to organize the medications (for a flat fee) since a caregiver cannot organize them
I would NOT like for a Registered Nurse to come 1-2 times a month to organize the medications (for a flat fee) since a caregiver cannot organize them
MEDICATION REMINDERS
Client needs the following assistance re medications from the Home Instead caregiver
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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)
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Please select
1. Senior has FULL capacity, will direct all decisions (no need to involve anyone else)
2. Senior has IMPAIRED capacity, will direct all decisions but please just inform the designated person below
3. Senior has IMPAIRED capacity, will direct all decisions but please get approval from designated person below (designated person below is authorized to disapprove of any decisions made by Senior)
4. Senior LACKS capacity, decisions need be made by designated person below
Name of Person who will assist with decisions
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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
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Please select
Senior is 100% independent (no assistance from caregiver necessary)
Senior requires some assistance from the caregiver (25%)
Senior requires significant assistance from the caregiver (50%)
Senior requires a lot of assistance from the caregiver (75%)
Senior requires total assistance from the caregiver (100% and wheelchair)
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
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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
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Please select one
The Service Agreement has been signed and executed already
The Service Agreement has NOT YET been signed and executed already but will be soon
We have questions about the Service Agreement and will call 212-614-8057 soon to discuss
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
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