Online Assessment

Please complete the form below to receive a quote for your required services. Please allow us 3 - 5 business days to get back to you with a quote. We guarantee that the information you provide will be kept 100% confidential and not be shared to any other 3rd party. Please allow 15 - 30 minutes for completion of this online assessment.

This assessment is for: *

Myself

A loved one

Applicant Information

Please fill out the following information about the person seeking home care services.

Applicant's First Name *

Required.

Applicant's Last Name *

Required.

Street Address *

Required.

City *

Required.

Province *

Required.

Postal Code

Applicant's Contact Number

Sex

Date of Birth

Contact Information

Please fill out the following contact information for whom you would like contacted regarding the outcome of this assessment.

First Name *

Required.

Last Name *

Required.

Relationship *

Required.

Contact Number *

Email *

Please enter a valid email.

Family Information Assessment

1. Who lives in the same household with the applicant?

Name	Age	Relationship	Remarks

None

2. List relevant family members.

Name	Age	Relationship	Remarks

None

3. Any other relevant information regarding applicant's family members or persons of importance

4. Applicant lives in:

House

Apartment

Senior Citizen Complex / Housing

Family Care / Foster Home

5. Indicate facilities available and adequacy

	Available (type)	Adequacy (Yes, no, if no explain)
Heating
Cooking
Refrigeration
Laundry
Drying
Water
Toilet
Bathing
Stairs
Telephone

6. Indicate if any of the above facilities (including their location) affect the ability of the applicant to function in home or to get outside:

7. Indicate if any of the above facilities (including their location) will affect the need for and delivery of services in the home:

8. Household tasks / management

	Formerly done by applicant	Still done by applicant	Remarks (indicate limitations)
Light Cleaning
Heavy Cleaning
Personal Laundry
Household Laundry
Shopping
Full Meal Preperation
Light Meal Preperation
Use Phone
Management of own Affairs

9. Any additional information about household tasks / management:

Health Information Assessment

10. Major Clinical Findings – Diagnosis / Extent of Disability:

Diagnosis known to family?

Yes

Diagnosis known to applicant?

Yes

11. Other relevant clinical history:

12. Allergies (if any, describe):

13. Medication

Medication	Dosage	Frequency	Route	Prescribed By	Date

Ability to administer medication:

Independant

Requires Assistance

14. Current prescribed treatments:

If any, indicate applicant's ability to manage own treatment:

Independant

Requires Assistance

15. Have clinical findings / treatment been confirmed with attending physician?

Yes

If yes, how? If no, what is the plan for confirmation:

16. Is applicant eating adequately?

Yes

Comments:

17. Is applicant on a special diet?

Yes

Comments:

Psycho / Social Information Assessment

30. Has applicant's living pattern / role in family or household altered in the past year?

31. Describe how the applicant spends his/her time in a typical day at home.

32. Are there any activities which the applicant formerly was engaged in at home which he/she now misses?

33. Are there any activities which the applicant formerly was engaged in at home which he/she now misses? (continued)

34. Are there any neighbours or friends in contact with the applicant?

Name	Address	Phone Number

35. Is the applicant involved within the community? (church, legion, fraternal, etc.)

36. Does travel outside the home affect applicant's ability to participate in activities, to receive medical care, to manage the household, etc.?

37. Specify cultural / religious preferences of applicant relevant to delivery of home care services (language, special food, etc.)

38. MENTAL STATUS

Completely oriented

Forgetful/Confused

Disoriented

39. MOOD

Seems content

Seems concerned about specific problem

Seems somewhat tense and anxious

Seems depressed

Unusual, unpredictable behaviour (specify)

Not motivated for some activities (specify)

40. MOTIVATION

Motivated for all activities

Not motivated for some activities (specify)

Not motivated fir most activities

41. JUDGMENT IN PRESENT SITUATION

Relastic

Adequate for personal safety

Limited ability to make judgements

Unrealistic

42. Any additional information regarding psycho / social functioning pertinent to assessment for delivery / home care:

Summary Assessment

Under the following headings indicate the area(s) (if any) where the applicant cannot meet need through self-functioning or through the services of available family or others, and which, if the need is not met, places the applicant at risk of not being able to remain in the community.

HOUSEHOLD MAINTENANCE NEEDS:

HEALTH NEEDS:

PERSONAL CARE NEEDS:

PSYCHO / SOCIAL NEEDS:

SUPPLIES / EQUIPMENT NEEDS:

Security Check

Please solve the sum *

What is 7 - 6 ?

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Applicant Information

Contact Information

Family Information Assessment

Health Information Assessment

Personal Care Information Assessment

Psycho / Social Information Assessment

Summary Assessment

Security Check