MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C76BA5.12DF52F0" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C76BA5.12DF52F0 Content-Location: file:///C:/8C74CAAD/ClientIntakeForm.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Confidential Consumer Intake Information & Assessment

Confidential Consumer Intake Information & Assessment=

 

Last Name: _________________________________  First Name: _____________________&n= bsp; Middle Initial: ___

Maiden Name:  _______________________  Nickname: ________________  Birth Date: __________________

Social Security Number: _____-_____-_______     Age: ______   Gender:   ___M   ___F    Race:_____________

Do you consider yourself Hi= spanic or Latino? _______    Primary Language: _____________________________

Street Address: _________________________________________      Telephone:=   ________________________

City: _______________________________   County: __________________    State: _____   Zip Code: _______

Mailing Address (if differe= nt from Street Address): _________________________________________________

City: _______________________________     State:  __________________      Zip Code:<= span style=3D'mso-spacerun:yes'>  _________________

Monthly Income Level:

       &= nbsp;   Single       &= nbsp;           &nbs= p;         Married

_____$850 or less       &= nbsp;  _____$1,140 or less

_____$851-$1,062       &= nbsp; _____$1,141-$1,425

_____$1,063-$1,275      _____= $1,426-$1,710

_____$1,276 or more     _____$1,711= or more
 

Marital Status:  Single ____      Marri= ed ____

       &= nbsp;           &nbs= p;       Widowed ____  Divo= rced ____

       &= nbsp;           &nbs= p;        Legally separated _____
 

Employment:   Full Time ____    Part Time ____

      Tempo= rary Jobs ____    Not Employed  ____
 

Hearing Problems:     Yes _____     No _____

Do you have a hearing aid?    Yes _____    No ____
 

Vision Problems:   Yes _____        No _____

Do you wear eyeglasses?   Yes ___   No ____
 

Volunteer Information: Willing to voluntee= r? ____

Currently volunteering? _____  As ______________
 

Are you a Veteran?   Yes _____    No _____

WWI or II  ____    = Korea ____   = Vietnam ____
 

Living Situation:

Living alone ______       &= nbsp;   Living with spouse or partner ______       &= nbsp;   Living with extended family _______ Living with non-relatives _________

 

Current Residence:

Own home _____      Rent home/apt.  _____      Assis= ted living _____    Family member’s residence _____

Homeless _____        Other _____
 

Emergency Information:

Emergency Contact : _________________________  Relationship: _______________= _  Phone: ___________

 

Primary Physician Name:  _____________________________= __  Physician’s Phone: ___________________
 

I have been informed of the policies regarding:=   voluntary contributions, comp= laint procedures, and appeal rights.  I hereby authorize the Department of Health & Human Service= s to release information regarding services I may be receiving to the Upper Arkansas Area Agency on Aging.

 

Signature ___________________________________________     Date ______________________________

 
 

Ple= ase complete questions on the back of form.
 

 


Nutrition Check List

Yes

No

Score

I have an illness or health condition that keeps me from eating the kinds a= nd amount of food I would like to eat.

 

 

2

Sometimes I eat less than two meals per day.

 

 

3

I eat few (two or less servings) fruits, vegetables or milk products a day.=

 

 

2

I have three or more drinks of beer, wine, or liquor a day.

 

 

2

I have teeth or mouth problems that make it hard for me to eat.<= /span>

 

 

2

Sometimes I don’t have enough money to buy the food I need.=

 

 

4

I eat alone most of the time.

 

 

1

I take three or more different prescribed or over-the-counter drugs a day.<= o:p>

 

 

1

Without wanting to, I have lost or gained ten pounds in the last six months.=

 

 

2

Sometimes I am physically unable to shop, cook and/or feed myself.

 

 

2

 

If an= swer is “yes,” circle the score.&nb= sp; Add the scores to determine your total nutritional score.        Total Score _____

Rating Scale:      =   0-2 =3D No Risk        =             &nb= sp;  3-5 =3D Moderate Risk        =         6 or more =3D High Nutritional Risk

Using the rating provided, if y= ou score 6 or higher, we strongly suggest you discuss this with your Primary C= are Provider immediately!

Activitie= s of Daily Living (ADLs)

Yes

No

I can eat without help.

 

 

I can dress myself without help.

 

 

I can bathe myself without help.

 

 

I can use the toilet without help.

 

 

I can get in and out of bed or chairs without help.<= /p>

 

 

I can get around inside my home without help.

 

 

Total Numbe= r of ADLs

 

 

 

Instrumen= tal Activities of Daily Living  (IADLs)

Yes

No

I can manage money without help.

 

 

I can take care of shopping without help.

 

 

I can take my medication without help.

 

 

I can prepare meals without help.

 

 

I can do ordinary housework without help.

 

 

I can use the telephone without help.

 

 

I can use transportation without help.

 

 

Total Numbe= r of IADLs

 

 

 

Are you currently receiving assistance with ADLs or IADLs from anyone?        Yes  _____        No _____

If yes, from whom are you r= eceiving assistance? ____________________________________________________

Do you cons= ider yourself to be frail?  _______=    Disabled?   ______

 

For Area Agency on Aging use only

Does th= e consumer require Home Health Aide based on orders from the physician?       Y= es       &nb= sp;          No

Is the consumer geographically isolated?       &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp; Yes       &nb= sp;          No       <= /p>

Can the consumer perform chore/heavy housework wit= hout help?     &nbs= p;    (Please comment)       &nb= sp;       Yes       &nb= sp;          No

Does the consumer reside in a rural area?       &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             Y= es       &nb= sp;          No       <= /p>

Is the consumer homebound?           &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ; Yes       &nb= sp;          No

What is= the consumer’s level of cognitive functioning?  Alert/oriented       &nb= sp;               &nb= sp;    Yes             &nb= sp;    No

Does the consumer require considerable assistance = in routine situations?   &n= bsp;            = ;            &n= bsp;       Yes       &nb= sp;          No

Comments:_________________________________________= ___________________________________________________________________________= _________________________________________________________
 

Revised 02/06

 
 
 

 

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