Client Form HR HUB DEFAULT ASSESSMENT FORMPATIENT PROFILEName First Middle Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneMobile PhoneWork PhoneEmail Address Referrer Source SSN Timezone Tags CONTACTSContact Type First Name Last Name Organization Relationship Primary Emergency POA Payer e-Payer Email Invoices Print on Care Plan Care NeedsInitial Contact: MM slash DD slash YYYY Start Date: MM slash DD slash YYYY Prognosis:PoorGuardedFairGoodExcellentCare Goals:Proposed Schedule:Care Coordination Notes:DemographicsDate of Birth: MM slash DD slash YYYY Date Of Death: MM slash DD slash YYYY Gender:MaleFemaleMarital Status:MarriedCohabitatingDomestic PartnershipSingleSeparatedDivorcedWidowedHeight: Weight: Spouse Name: Lives With: Religion:ChristanityJudaismBuddhismIslamHinduismOtherUnaffiliatedAttends Services:UnknownYesNoDNR:YesNoUnknownLanguages:EnglishSpanishArabicArmenianMandarinFrenchFrench CreoleGermanGreekGujaratiHindiItalianJapaneseKoreanPersianPolishPortugueseRussianTagalogUrduVietnameseOtherHebrewCantonesePast Profession: Note:Before you edit or delete any existing tasks that are currently on the client's schedule, please be SURE that you have updated those tasks on the Care Plan and updated the shifts using the clock icon next to each task. Failure to do so may result in outdated tasks on the client's schedule.Activities of Daily Living (ADLs)Note: Before you edit or delete any existing tasks that are currently on the client's schedule, please be SURE that you have updated those tasks on the Care Plan and updated the shifts using the clock icon next to each task. Failure to do so may result in outdated tasks on the client's schedule.Instrumental Activities of Daily Living (IADLs)ActivitiesICD9 CodesCode Name ICD10 CodesCode Name Diagnosis Date MM slash DD slash YYYY Fields required for payers using the UB-04 invoice formatPatient Control Number (box 3a): Medical Record Number (box 3b): Medical ConditionsList any chronic or acute conditions as well as recent hospital/skilled nursing stays:Hearing Good Poor Deaf Hearing Aid Speech Good Poor None Vision Good Poor Blind Swallowing Good Poor None Other: Smoker Sensitive To Smell On Oxygen Colostomy Bag Feeding Tube Functional Limitations: Amputation Bowel/Bladder (Incontinence) Contracture Hearing Paralysis Endurance Ambulation Speech Legally Blind Dyspnea with Minimal Exertion Mental/Behavior ConditionsDiagnosed Disorders / Medications: Depression Lethargy Past/Current Substance Abuse Can client be left alone?UnknownYesNoWanderer?UnknownYesNoDementiaNoForgetfulMildModerateSevereSymptoms: Frequent Mood Changes Hallucinations Problem Solving Short Term Memory Loss Completing Task Sundowning Spatial/Visual Relationships Misplacing Items Poor Eating Speaking/Conversing Poor Judgment Sleeping Problems Anxiety Agitation Fear Paranoia Suspicion Aggression Confusion of Time/Place Withdrawal Depression Repetition Wandering Oriented Comatose Triggers:AllergiesAllergies: Notes:EliminationIncontinence Urination Bowels Wears Briefs Issues Constipation Diarrhea NotesMedication and SupplementsNeeds medication / supplement reminders?UnknownYesNoWho manages medications / supplements? Number of medications / supplements123456789101112131415161718192021222324252627282930Is there a separate medication / supplement schedule sheet?UnknownYesNoMedications / Supplements set up in pill boxes?UnknownYesNoHow many weeks?12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152ForeverNotesMedicationsMedication / Supplement Name Client is actively taking this Form Dosage Schedule Regular Schedule As Needed (PRN) Reason/Description NotesMedication ScheduleAdd time to schedule: Hours : Minutes AM PM AM/PM What time is the medication / supplement administered? AmbulationAids: Cane Walker Wheel Chair Scooter Geri Chair Use of Left Arms/Hands Use of Right Arms/Hands Fall Risk: Fall Risk No History Poor Balance NotesTransfersTransfer Types Aids Gait Belt Hoyer Other Transfer Risks NotesBathing, Grooming & Dressing Uses Shower Bench Resists Bathing Method Shower Bath Sponge Bath Frequency Hygiene Dental/Dentures Care Skin Care Other Other (Detail) DressingDressingDresses SelfLight AssistanceHeavy AssistanceTotal AssistanceNotesMealsAssistance Cooking Preparation Feeding AppetitePoorGoodDietDietPoor NutritionDesires Improves NutritionSpecial DietSpecial Diet Shopping By TimeBreakfast Hours : Minutes AM PM AM/PM Lunch Time Hours : Minutes AM PM AM/PM Dinner Time Hours : Minutes AM PM AM/PM Snack Time Hours : Minutes AM PM AM/PM Other Swallowing Issues Encourage Liquids Favorite FoodsFavorite Breakfast Favorite Lunch Favorite Snack Favorite Dinner NotesDrivingVehicle: Client Drives Needs Caregiver To Drive Select a carAide's CarClient's CarOther: Errands Doctor's Appointment(s) Errands Details Appointment Details Notes:Sleep Patterns:Goes To Bed: Hours : Minutes AM PM AM/PM Wakes Up: Hours : Minutes AM PM AM/PM Difficulty Returning To Sleep Sleep Patterns: Sleeps through night Frequently awakens Gets up for toileting Needs assistance at night from caregiver Naps During Day Time: Hours : Minutes AM PM AM/PM Duration0:150:300:451:001:151:301:452:002:152:302:453:00Notes:Equipment/Environment:Has safety assessment been done?YesNoInterested in Lifeline?YesNoEquipment Bedrails Hospital Bed Bed Commode Grab Bars Lift Chair Raised Toilet Seat Shower Bench Handheld Showerhead Other Notes:Pet Care Cat Clean Litter Box Dog Feeding Walk Dog Other Pet Notes:Daily RoutineActivities Permitted Complete Bedrest Transfer Bed Chair Independent At Home Wheelchair Bedrest BRP Exercises Prescribed Crutches Walker Up As Tolerated Partial Weight Bearing Cane No Restrictions Daily RoutineMorning:Afternoon:Evening:ActivitiesActivities at Home: (e.g. Reading, Board Games, Hobbies, Music):Activities Away from Home: (Parks, Gardens, Outings, Lunches, etc.):Favorite Restaurants/Shops:Family/Friends/Neighbors:EmailThis field is for validation purposes and should be left unchanged. 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