ADLS & IADLS Client Assessment Form About this FormClient Contact InformationPrimary PhysicianGov't Funded Care & HSTCOVID-19 Screening (1 of 2)COVID-19 Screening (2 of 2)Current HealthMedical HistoryBehaviors & InterestsMedical DevicesOxygen NeedsServices NeededEmergency ContactAlternate ContactInvoicing & PaymentComplete only the information you believe is required for us to provide personal support. If you have any questions, feel free to contact our Care Manager - Lynn Paltooram at (833) 779-2273. Information gathered is used for assessment purposes only and data is not shared with any 3rd parties. PreviousNextClient Contact InformationFirst NameMiddle NameLast NameAddressCityPostal CodePhone/MobileEmailDate of BirthPreviousNextPrimary PhysicianPhysician NamePhysician PhoneLocation of Health CardPreviousNextLHIN / CCAC ServicesIs the client currently receiving publicly funded services from LHIN / CCAC? If yes, HST will not be charged on invoices. Yes NoLHIN Client Number or BRN number. ** This number must appear on invoices for HST exemption. **Is the client receiving services from other home care services providers/caregivers ? Yes NoPreviousNextCovid-19 ScreeningDoes the client show any of the following symptoms?YesNoFeeling feverishNew loss of smell or tasteNew or worsening coughShortness of breath or difficulty breathingMuscle or body achesTemperature equal to or more than 38°CChills and or headachesSore throatPreviousNextCovid-19 ScreeningAny travel outside of Canada in the last 14 days? Yes NoWhen did you return to CanadaAny contact with a confirmed or probable COVID-19 case? Yes NoHow many days since contact with a confirmed or probable case of COVID-19? Less than 14 days Over 14 daysHas the client received a COVID-19 vaccine? Yes NoHow many doses? 1 2 3 4If unvaccinated, does the client have a medical exemption? Yes NoPreviousNextCurrent Health ConditionMedical Diagnosis/ Present ConditionWhat is the prognosis?PalliativeImproveDeteriorateRemain stableUnknownPreviousNextMedical HistoryPlease indicate only those conditions that impact the client's current health. Arrhythmia Asthma Alzheimer's Arthritis Cancer Chronic Bronchitis Coronary Heart Disease Chronic Kidney Disease COPD Deep Vein Thrombosis Diabetes Dementia Heart Attack High Cholesterol Hypertension Osteoporosis Motor Neurone Disease Multiple Sclerosis Paget’s Disease of Bone Parkinson's Shingles StrokePreviousNextDescribe any current behaviour and behaviour during the past 12 months (e.g., wandering, physical, verbal or sexual aggression and potential for violent behaviour). Include frequency of exhibited behaviours, triggers and interventions.Does the client have any drug sensitivities, allergies, and/or addictions? Yes NoList any drug sensitivities, allergies, and/or addictionsIs the client taking any prescription medications? Yes NoMedication management Individual self manages medication Needs supervision with medication Needs assistance with medicationWhere are the medications located?PreviousNextMedical & Assistive DevicesYesNoBed RailsBriefsCanesDenturesGlassesYesNoHearing AidsLift ChairMedic AlertRollator / WalkerWheel ChairPreviousNextOther Aids / DevicesDoes the client require oxygen? Yes NoIf "Yes", specify Tank Concentrator Mask Nasal prongsPreviousNextPersonal Support ServicesActivities that Require Assistance Assistance with Feeding Bathing & Hygiene Companionship Dressing & Undressing Groceries & Errands Light Housekeeping Mealtime Assistance (Meal Prep) Medication Reminders Mobility/Transfers/Lifts Toileting Walking & ExercisingOther Support ServicesActivities & Interests - (ex. Foods, Snacks, TV Shows, Music, Topics of Conversation)PreviousNextEmergency Contact InformationIs there an Emergency Contact Person? Yes NoContact First NameLast NameRelationship to ClientStreet AddressCityPostal CodeWork PhoneMobile PhoneEmailPreviousNextIs there an Alternate / Secondary Emergency Contact? Yes NoContact First NameLast NameRelationship to ClientStreet AddressCityPostal CodeWork PhoneMobile PhoneEmailPreviousNextInvoices & PaymentIs there a Power of Attorney No Primary Contact has POA Alternate Contact has POA OtherContact First NameLast NameRelationship to ClientStreet AddressCityPostal CodeWork PhoneMobile PhoneEmailSend Invoices To- Select -ClientPrimary ContactCCAC / LHINInsurance CompanyPower of AttorneyWSIBVeterans AffairsOtherMethod of PaymentChequeE-TransferCredit CardWSIB Policy#Veterans Affairs Reference#Insurance CompanyPhone NumberContact NamePolicy NumberClaim NumberContact First NameLast NameRelationship to ClientStreet AddressCityPostal CodeWork PhoneMobile PhoneEmailThank You!Please enter "previous" to make a change. Hit the submit button to send your completed form.PreviousSubmit Form