Intake - All Families Home Health Services INC.

Skip to content

[email protected]
767 E High St Carlisle, PA 17013
(240) 334-8918
(240) 575-5399

Facebook-f Instagram

Home
About
Services
- Personal Care Services
Blog
Careers
Forms
Service Areas
Contact

Home
About
Services
- Personal Care Services
Blog
Careers
Forms
Service Areas
Contact

Schedule Appointment

"*" indicates required fields

PRE-VISIT INTAKE QUESTIONNAIRE

Date of Evaluation:*

MM slash DD slash YYYY

DEMOGRAPHIC INFORMATION

Full Name*

First Name: Middle Name: Last Name:

Your Address*

Street Address: Apartment/Unit (if applicable): City: State: ZIP Code:

Phone Number:*

Date of Birth:*

MM slash DD slash YYYY

Age:

Email:*

Gender:*

Male

Female

Who is your primary care provider?*

Email:

Address:*

Phone Number:*

Fax Number:

May we contact your physician?*

Yes

No

PRESENTING PROBLEM

Please briefly describe what problem(s) with thinking you are experiencing:

Please indicate if you are independent or need help with any of the following.

Task

Need Help

Feeding yourself

Feeding yourself Yes/No

Yes

No

Driving

Driving Yes/No

Yes

No

Incontinence

Incontinence Yes/No

Yes

No

Bathing

Bathing Yes/No

Yes

No

Dressing

Dressing Yes/No

Yes

No

Transferring

Transferring Yes/No

Yes

No

Homemaking

Homemaking Yes/No

Yes

No

Ambulation

Ambulation Yes/No

Yes

No

Meal Prep

Meal Prep Yes/No

Yes

No

Med Reminders

Med Reminders Yes/No

Yes

No

Do you receive help in your home (e.g. family member, paid home health worker)?

Yes

No

How many days per week?

How many hours per day?

Who Helps?

MEDICAL HISTORY

Eye and Ear Problems

Heart Problems

Cataracts

Yes

No

Heart attack

Yes

No

Glaucoma

Yes

No

High Blood Pressure

Yes

No

Macular Degeneration

Yes

No

Heart Failure

Yes

No

Hearing Loss

Yes

No

Irregular Heartbeats (arrhythmia)

Yes

No

Do you use hearing aids?

Yes

No

Atrial Fibrillation

Yes

No

Do you utilize corrective lenses?

Yes

No

Aortic Stenosis

Yes

No

Other:

Other:

Lung/Pulmonary Problems

Bone and Joint Problems

Asthma

Yes

No

Gout

Yes

No

Emphysema

Yes

No

Osteoporosis

Yes

No

COPD

Yes

No

Fracture

Yes

No

Bronchitis

Yes

No

Other:

Other:

Metabolic/Endocrine Problems

Urinary and Kidney Tract Problems

Diabetes

Yes

No

Kidney Disease

Yes

No

Hyperthyroid/High Thyroid

Yes

No

Prostate Disease

Yes

No

Hypothyroid/Low Thyroid

Yes

No

Frequent Bladder Infections/UTI

Yes

No

Pituitary Gland Tumor

Yes

No

Other:

Hashimoto’s Disease

Yes

No

Other:

Neurological Conditions

Dementia

Yes

No

Huntington’s Disease

Yes

No

Type Identified:

Stroke

Yes

No

Toxin Exposure

Yes

No

Date

MM slash DD slash YYYY

Type:

Date:

MM slash DD slash YYYY

Epilepsy/ Instances of Seizures

Yes

No

Head Injury

Yes

No

Number of Injuries:

Date of Injury:

MM slash DD slash YYYY

Parkinson’s Disease

Yes

No

Other:

Gastrointestinal Problems

Other Health Conditions

Ulcers

Yes

No

Allergies

Yes

No

Diverticulitis

Yes

No

High Cholesterol

Yes

No

Heartburn

Yes

No

Sleep Apnea

Yes

No

Irritable Bowel Syndrome

Yes

No

Blood Disorders

Yes

No

Crohn’s Disease

Yes

No

Thrombosis

Yes

No

Celiac Disease

Yes

No

Cancer

Yes

No

Ulcerative Colitis

Yes

No

Sexual Dysfunction

Yes

No

Gallbladder Disease

Yes

No

Recent Physical Symptoms

Other Health Conditions

Loss of Consciousness/Fainting

Yes

No

Tremors

Yes

No

Dizziness

Yes

No

Shuffling/Slow Gait

Yes

No

Loss of Balance

Yes

No

Low Energy

Yes

No

Headaches

Yes

No

Shortness of Breath

Yes

No

Change in smell

Yes

No

Change in taste

Yes

No

Incontinence

Yes

No

Bowel Issues

Yes

No

Blurred Vision

Yes

No

Mis-reaching for items (e.g. door handles)

Yes

No

Neuropathy/ Loss of Sensation/Tingling

Yes

No

Sleep Difficulties

Yes

No

Slurred Speech

Yes

No

Difficulties Swallowing:

Yes

No

SURGERY

Date

1.

Date

MM slash DD slash YYYY

2.

Date

MM slash DD slash YYYY

3.

Date

MM slash DD slash YYYY

HOSPITALIZATION REASON

Date

1.

Date

MM slash DD slash YYYY

2.

Date

MM slash DD slash YYYY

3.

Date

MM slash DD slash YYYY

Signature

Name

This field is for validation purposes and should be left unchanged.

Facebook-f Instagram

Get In Touch

(240) 334-8918
(240) 575-5399
[email protected]
767 E High St Carlisle, PA 17013

Quick Links

About
Blogs
Careers
Service Areas
Contact

© All Families Home Health Services INC – Powered by

Quick Inquiry

Name(Required)

Phone(Required)

Email(Required)

Message Us:

Email

This field is for validation purposes and should be left unchanged.

Schedule Appointment

Name(Required)

Phone(Required)

Email(Required)

Best time to Call

Message Us:

Name

This field is for validation purposes and should be left unchanged.