Client In-Home Assessment & Care Plan | Golden Grace Health Care LLC

1. Client Information

Client Name *DOBAgeWeightHeightMarital StatusSpouse NameWho else lives in the homePetsOccupationHobbiesAddressCity/State/ZipPhonePrimary LanguageEmergency Contact NameRelationshipPhoneWhere should the caregiver park

How should the caregiver enter the home

Entry notes

2. Physician & Medical Information

Primary PhysicianPhysician PhoneMedical Diagnoses / ConditionsRecent Hospitalizations (last 12 months)Allergies

Hearing

Vision

Speech

Swallowing

Walking

Other

3. Medication Overview

Medication 1

Medication NameDoseFrequencyManaged byAssistance NeededReminders

Medication 2

Medication NameDoseFrequencyManaged byAssistance NeededReminders

4. Cognitive Status

Alert / Oriented

Alzheimer’s / Dementia Diagnosis

Memory Issues

Behavioral Concerns

5. Activities of Daily Living (ADLs)

Bathing

Dressing

Toileting

Transferring

Ambulation

Eating

6. Instrumental Activities of Daily Living (IADLs)

Meal Preparation

Housekeeping

Laundry

Transportation

Medication Reminders

Shopping / Errands

7. Mealtimes

Breakfast: TimePreferred mealLunch: TimePreferred mealDinner: TimePreferred mealSnackPreferred snacksBeverage

Feeding

Appetite

8. Sleep Time

Goes to bed atWakes up atNaps

Sleeps through the night

Frequently wakes up

Wakes to toilet

Difficulty falling back asleep

9. Home Safety & Fall Risk Assessment

History of Falls (last 12 months)

Uses Assistive DevicesAdequate LightingRoom/Walkways free from clutterSpecial Precautions for Caregiver

10. Service Needs / Care Plan

Services Requested

Service detailsPreferred ScheduleCare GoalsSpecial Instructions for Caregivers

11. Assessment Summary

Summary of client condition and recommended care plan

12. Signatures

Client / Responsible Party Name *

Signature *

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.

DateGolden Grace Representative Name

Signature

By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.

Date