Care Questionaire

Client Care Needs Questionnaire

Purpose: This helps us build a safe, personalized care plan before services begin.

Privacy note: Please share only what is needed for care planning. We keep information confidential and use it only to coordinate care.

1) Client Information

Client full name
Date of birth
Client address
Primary language

Responsible Person (Completing This Form)

Name
Relationship to client
Phone
Email
Emergency contact (name + phone)

2) Medical & Health Information

Primary diagnosis / main health concerns
Other medical conditions (if any)
Allergies
Recent hospitalizations (date + reason)

Mobility level (check one)
Independent
Uses walker
Uses wheelchair
Needs hands-on assistance

Vision/hearing concerns

3) Daily Living Needs (ADLs)

Check all that apply:

Bathing Dressing Toileting Eating Transferring (bed/chair) Walking Grooming Continence care

Please describe the level of help needed

4) Medication Support

Client takes medications

Who manages medications now?
Needs medication reminders

Special instructions (timing, food, PRN, etc.)

5) Cognitive & Emotional Status

Memory concerns
Diagnosed dementia/Alzheimer’s
Confusion at certain times of day
Anxiety/depression concerns

Behavioral concerns (if any)

6) Safety & Fall Risk

History of falls
Wandering risk
Uses oxygen

Home safety concerns (stairs, rugs, pets, etc.)

7) Personal Care Preferences

Preferred wake-up time
Preferred bedtime
Bathing preference (shower / sponge / other)
Food preferences / dietary restrictions
Cultural / religious considerations (if any)
Likes / dislikes / comfort items

8) Household Support

Meal preparation Light housekeeping Laundry Shopping/errands Transportation Companionship

Please explain

9) Communication & Routine

Preferred communication style
Speech difficulties (if any)
Typical daily routine

10) Family Goals & Expectations

Main goals for care
Biggest concerns
What would a “good day” look like?

11) Schedule & Coverage

Days needed
Hours needed
Preferred start date

12) Additional Notes

Consent

By submitting this form, I confirm the information provided is accurate to the best of my knowledge and may be used to create a personalized care plan.

Printed name
Relationship to client
Date