New Client Enrollment Form

Name

Client Preferred Name

Client Preferred Gender Pronouns

Marital Status Marital Status Single Married Divorced Separated Widowed

Please select where we will be providing services Please select where we will be providing services Nursing Home Client's Home Family Member's Home Other

If you chose other, where will we be providing services?

Please select service hours Please select service hours Part Time Full Time

Please specify service times and days

How were you referred to Care Done Right? Or, how did you find out about our services?

Main Contact Person

Main Contact Person Email

Phone Number

Relationship Relationship Spouse Partner Cousin Friend Child Sibling Uncle / Aunt Guardian

Health Care Proxy Name

Health Care Proxy Phone Number

Health Care Proxy Relationship Health Care Proxy Relationship Spouse Partner Cousin Friend Child Sibling Uncle / Aunt Guardian

Physician Name

Name of Hospital

Phone Number

Address

City

State

ZIP / Postal Code

Current activity status of client? Current activity status of client? Self bath/assistance need Dress self Feed self Brush teeth Shave self Toilet Bed pan Urinal Other

Current physical status of client? Current physical status of client? Ambulation-independent/assistance-needed Bed to chair Walking Stairs Wheel chair Crutches Cane Bed rest Other

Client's method of communication Client's method of communication Verbal Nonverbal

Language(s) spoken

Language(s) understood

Check if client has been diagnosed with any of the following: Check if client has been diagnosed with any of the following: Diabetes Hypertension Seizures/Epilepsy Heart Disease Cancer Thyroid Issues Blood Disorder Anemia Asthma Allergies Hepatitis Kidney Problems HIV Exposure Liver Problems Tuberculosis (TB) Urinary/Bladder Problems Pelvis/Back Problems Stomach/Digestive Issues Skin Disorders Bladder Infection Kidney Infection Severe Headaches Ear/Hearing Problems Eye/Vision Problems Vascular Issues (varicose veins, blood clots, etc.) Hemorrhoids None Other

Describe any checked boxes here

Please list all allergies or sensitivities

Please check if the client has ever been diagnosed or suspected of having any of the following: Please check if the client has ever been diagnosed or suspected of having any of the following: Depression Bi-Polar Disorder Anxiety Panic Attacks Delusions Paranoia Psychosis Anorexia Bulimia PTSD None Other

If you indicated any of the above conditions, please describe below

Smoking Status Smoking Status Current every day smoker Current some day smoker Former smoker Never a smoker

Nutrition

Exercise Habits

Sleep Habits

Hobbies