Health Assessment

Complete this form to help us understand your current health status and care needs.

Confidential 10-15 minutes

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SECTION 1: CURRENT HEALTH PROFILE - A. Diagnoses

Check all that apply:

☐ Diabetes ☐ Heart disease / CHF ☐ High blood pressure ☐ COPD / Breathing ☐ Stroke history ☐ Parkinson's disease ☐ Arthritis ☐ Dementia / Alzheimer's ☐ Depression ☐ Anxiety ☐ Cancer (current/past) ☐ Kidney disease ☐ Neuropathy ☐ Seizures / Epilepsy ☐ Osteoporosis ☐ Thyroid (hypo/hyper) ☐ Glaucoma ☐ Cataracts ☐ Macular degeneration ☐ Hearing loss ☐ Pre-diabetes ☐ Fall risk / Dizziness ☐ Bladder problems ☐ Sleep disorder ☐ Fibromyalgia ☐ Atrial fibrillation

Other diagnoses:

Any new diagnoses or major health changes in the last 6 months?

○ No ○ Yes

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SECTION 2: DAILY MANAGEMENT & CARE CONSIDERATIONS

Based on your diagnoses, what do you do daily to manage your health?

Special care considerations:

☐ Fluid restriction ☐ Special diet ☐ Swallowing precautions ☐ Uses oxygen ☐ Catheter ☐ Wound care ☐ Insulin injections ☐ Nebulizer / Inhaler

Home monitoring:

☐ Blood sugar ☐ Blood pressure ☐ Oxygen levels ☐ Daily weight ☐ INR (Warfarin)

Pain: Do you have any pain that affects your daily life?

○ No pain ○ Yes

Skin: Any skin concerns we should know about?

☐ No concerns ☐ Open wound ☐ Pressure areas ☐ Skin tears ☐ Rash ☐ Easy bruising ☐ Foot issues

Nutrition: Have you had any unexpected weight changes in the past 6 months?

○ No change ○ Gained weight ○ Lost weight

Who prepares your meals?

○ I do myself ○ Family member ○ Caregiver ○ Meals on Wheels / Service

Do you have any food or medication allergies?

○ No ○ Yes

(Complete allergen exposure plan)

Any new diagnoses or major health changes in the last 6 months?

○ No ○ Yes

Any other daily routines or care considerations related to your health conditions?

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SECTION 3: MEDICATIONS

Tell us about your medication management

Who manages your medications?

○ I manage myself ○ Spouse/Partner ○ Family member ○ Caregiver ○ Pharmacy blister pack

Do you use any medication reminders or aids?

☐ Pill box/organizer ☐ Alarm/phone reminder ☐ Calendar ☐ No reminders needed

Have you had any issues taking medications as prescribed?

○ No issues ○ Yes

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SECTION 4: RECENT HEALTH EVENTS (Last 6 Months)

☐ Hospitalization ☐ ER visit ☐ Surgery ☐ Rehab / Skilled Nursing stay ☐ Fall with injury ☐ New medication started ☐ General decline in strength or stamina ☐ Stopped driving ☐ Death of someone close ☐ Major life change ☐ None of the above

If any apply, please explain briefly:

Any current restrictions from your doctor?

○ No ○ Yes

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SECTION 5: MOBILITY, FALLS & BALANCE

Have you fallen in the past year?

○ No ○ Once ○ 2–3 times ○ More than 3 times

Do you feel unsteady when walking?

○ Never ○ Sometimes ○ Often ○ All the time

Mobility aids used:

☐ None ☐ Cane ☐ Walker ☐ Rollator ☐ Wheelchair ☐ Scooter

Do you use your mobility aid consistently?

○ Always ○ Mostly ○ Sometimes ○ Rarely

What movements are hardest? (Check all that apply)

☐ Stairs ☐ Standing up ☐ Walking distances ☐ Uneven surfaces ☐ Getting in/out of bed ☐ Getting in/out of tub/shower ☐ Getting on/off toilet ☐ Getting in/out of car

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SECTION 6: BLADDER & BOWEL (Confidential)

Bladder concerns:

☐ None ☐ Leakage ☐ Urgency ☐ Frequent nighttime urination ☐ Accidents ☐ Catheter

Bowel concerns:

☐ None ☐ Constipation ☐ Diarrhea ☐ Accidents ☐ Ostomy

Do you use protective products?

○ No ○ Pads/liners ○ Briefs

Can you manage independently?

○ Yes ○ Need some help ○ Need full help

Does this affect your willingness to leave home or have visitors?

○ No ○ Sometimes ○ Yes

Privacy preferences related to this:

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SECTION 7: VISION & HEARING

Vision:

☐ No issues ☐ Difficulty reading medication labels ☐ Trouble recognizing faces ☐ Poor night vision ☐ Glaucoma ☐ Macular degeneration ☐ Cataracts ☐ Legally blind

Hearing:

☐ No issues ☐ Hearing aids ☐ Trouble following conversation ☐ Cannot hear phone/doorbell ☐ Difficulty hearing in groups ☐ Deaf / near-deaf

Best way to communicate with you:

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SECTION 8: LIVING SITUATION & SAFETY

Living situation:

○ Live alone ○ With spouse/partner ○ With family ○ With live-in caregiver ○ Assisted living

If not alone, who lives with you?

How long are you alone each day?

○ Never ○ A few hours ○ Most of the day ○ All day & night

Can someone reach you quickly in an emergency?

○ Yes ○ Limited ○ No

Safety supports in your home:

☐ Grab bars ☐ Shower chair ☐ Emergency response pendant ☐ None of these

Any parts of the home you avoid due to safety concerns?

Do you currently drive?

○ Yes ○ No, I no longer drive ○ Family provides transportation

Cognition & Memory

Do you have any concerns about your memory or thinking?

○ No concerns ○ Some concerns ○ Yes, significant concerns

Do you use any memory aids?

☐ Calendar ☐ Phone reminders ☐ Pill organizer ☐ Caregiver reminders ☐ None

Any other cognitive concerns?

Do you have any allergies?

○ No known allergies ○ Yes

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SECTION 9: SUPPORT & SOCIAL CONNECTION

Who would you call in an emergency?

Who checks on you regularly?

☐ Family member ☐ Friend / neighbor ☐ Caregiver ☐ Senior center / program ☐ No one

How often does someone physically visit or check on you?

○ Daily ○ A few times a week ○ Weekly ○ Rarely / never

Do you ever feel lonely or isolated?

○ Never ○ Sometimes ○ Often ○ Always

What activities do you enjoy? (hobbies, interests, groups)

Phone number we can call:

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SECTION 10: CARE GOALS & EXPECTATIONS

What are your main goals for receiving home care? (Check all that apply)

☐ Stay independent at home ☐ Avoid moving to a nursing home ☐ Have companionship & reduce loneliness ☐ Stay safe and prevent falls

Other goals not listed above:

What does a "good day" look like for you?

How important is it to maintain your current daily routine?

○ Very important — I have a routine I want to keep ○ Somewhat important ○ I'm flexible — whatever works is fine

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SIGNATURE & AUTHORIZATION

By signing below, I certify that the information provided in this assessment is accurate and complete to the best of my knowledge. I authorize Silver Home Care to use this information to develop a personalized care plan.

Client Signature:

Date:

Print Name:

Relationship to Client:

If someone other than the client is signing:

Representative Signature:

Date:

Your information is confidential and protected by our privacy policy.