LarCare/SamariCare Home Care Assessment Form

Location *

1. Client Information

Client First Name *

Client Last Name *

Date of Birth *

Street Address

City

State/Region/Province

Postal / Zip Code

Phone

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone

Primary Care Physician (title, first, last)

Physician Phone

DNR

Advance Care Directive

Hospital of Choice

2. Medical History & Current Conditions

Primary Diagnosis

Chronic Conditions (comma-separated: Diabetes, Dementia/Alzheimer's, Parkinson's, Stroke, COPD, CHF, Arthritis, Cancer, Other)

Allergies

Current Medications (name, dose, taken — one per line)

Recent Hospitalizations (Last 6 Months)

If Yes, Reason

3. Functional Abilities (ADLs & IADLs Assessment)

Bathing *

Dressing *

Grooming *

Toileting *

Mobility (Walking) *

Transferring (Bed/Chair) *

Eating *

Medication Management *

Meal Preparation *

Housekeeping *

Transportation *

Money Management *

4. Cognitive & Behavioral Assessment

Oriented to Time & Place? *

Memory Issues

Wanders or Gets Lost? *

Mood or Behavioral Issues (comma-separated: Depression, Anxiety, Agitation, None)

5. Home Safety & Environment

Home Has (comma-separated: Stairs, Grab Bars in Bathroom, Ramps, Smoke Detectors)

Is There a History of Falls? *

If Yes, When

Are There Pets in the Home? *

If Yes, Type

6. Caregiver & Support System

Does the Client Live Alone? *

Primary Caregiver Name (title, first, last)

Relationship to Client

Caregiver Availability

Other Support Services in Place (comma-separated: Home Health Nurse, Physical Therapy, Occupational Therapy, Meals on Wheels, Transportation Services)

7. Home Care Services Requested

Services Requested (comma-separated: Personal Care, Medication Reminders, Light Housekeeping, Meal Preparation, Transportation, Dementia/Alzheimer's Care, 24/7 Live-in Care, Companionship) *

8. Notes & Care Plan Recommendations

Notes & Care Plan Recommendations

Next Steps

RN Signature — type your full legal name to sign *

Date of Assessment *

Reviewed by Agency Supervisor (title, first, last)

What Are the Caregiver Needs

Hours Needed

Days of the Week (comma-separated) *