Nurse Assessment

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The Lab Program
Nurse Assessment

Home
About Us
Services
Appointment
Careers
Contact Us
The Lab Program
Nurse Assessment

Make Appointment

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Name

Phone

Time

Date Of Birth

Address

Primary Contact Person (if different from client)

Primary Contact Phone Number

Relationship to Client:

Do you have any chronic health conditions?

Yes No

If Yes ( Please Specify)

Diabetes Heart Disease Arthritis Alzheimer’s/Dementia Parkinson’s Disease Stroke

Other (Please specify): ___________

Do you require assistance with medications?

Yes No

If yes, how often?

Daily Weekly As Needed

Do you require assistance with any of the following?

Bathing Dressing Grooming Toileting Eating Mobility/Transfers (e.g. From bed to chair) Walking Getting in and out of bed.

Do you experience memory problems?

Yes No

Have you been diagnosed with a cognitive disorder (e.g., dementia)?

Yes No

Do you experience any of the following emotional states frequently?

Anxiety Depression Agitation Lonliness

Other (Please specify): ___________

Do you experience any of the following emotional states frequently?

Ramps or grab bars Stairlifts A medical alert system Smoke detectors/carbon monoxide detectors

Other safety equipment (please specify)

Are there any home safety concerns?

Yes No

If yes, please describe: ___________

How many hours per day do you need care?

Less than 4 hours 4–6 hours 6–8 hours 8+ hours 24/7 Car Live in Care

Days of the week when care is needed:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred start time for care

Morning Afternoon Evening

Are there any other specific concerns or needs you’d like to mention?(Please provide details)

Do you have insurance or a funding source to cover home care services?

Yes No

How do you plan to fund your care services?

Private Pay Long-term care insurance

1340 Environ way chapel hill NC 27517 suite 337
billie@lifeandabundanceent.com
919-913-4777

Services

PCA
Companion Care
Light Housekeeping
Other Service

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