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Please provide your contact information below. Then tell us as much as you can about the client’s needs so we may best respond to your inquiry.
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Patient's First Name:
Patient's Last Name:
Has this patient previously received home care services?	Yes No
If so, when?:
Screening - Does Client:
Use Telephone?	Yes No
Get out of bed unassisted?	Yes No
Walk unassisted?	Yes No
Operate a motor vehicle?	Yes No
Shop for essentials?	Yes No
Handle money/pay bills?	Yes No
Prepare Meals?	Yes No
Eat Unassisted?	Yes No
Do routine housework?	Yes No
Do laundry?	Yes No
Dress and undress self?	Yes No
Shower/Bathe/Groom self?	Yes No
Get to toilet in time?	Yes No
See physician frequently?	Yes No
Follow medical directions?	Yes No
Have prescribed medications?	Yes No
Have diabetes?	Yes No
Receive home health?	Yes No
Have a physician?	Yes No
Have physician-ordered therapies?	Yes No
Have adequate informal support?	Yes No
Seem confused?	Yes No
Have ability to share in cost of care?	Yes No