Care Enquiry July 1, 2016 by admin 2153 We are happy to arrange a free in-home assessment Tell us about your home care needs Name of the person needing support * Your E-Mail * Phone Number * Fax Number: How soon you need the service ---Immediately2-3 Weeks4-6 Weeks1 yearOther Address of person needing support * Relationship to you *---My SelfMy MotherMy FatherMy HusbandMy SisterMy BrotherMy PartnerA GrandparentAn AuntAn UncleA ChildA Friend/NeighbourOther Age of person seeking support * Support currently being received:---Living with Relatives/FriendsLiving close to Relative/Friends who check-inRelatives/Friends live out of town but visitNo Relatives or FriendsOther Mobility of the person needing Support:---No problem with MobilityStumble from Time to TimeFallen RecentlyDifficulty Walking UpstairsUse Cane or Walker for securityNeed help to get out of a chairNot Certain Any Health Problems: * Arthritis Cancer Stroke Heart Disease Open wounds Alzheimer's or Dementia Pain Parkinson's Disease Diabetes Brain Injury Lung Problem Recovering from surgery Other None Current level of assistance: * No assistance Family/ Friends assistance Government agency Private Insurance Paying privately for assistance Not certain - Please advice Persons Lifestyle Needs: * Shopping Buying Groceries House Cleaning/laundry Cooking meals Companionship Medication Reminders Monitoring Mobility Running errands Not certain-Please assess Personal Care that needs assistance * Do not have any personal care needs at this time Getting in and out of Bathtub/Washing hair Brushing hair/Cleaning Teeth/shaving,etc Using the commode Getting dressed and undressed Not certain -Please assess
