Question? Need FREE help? Call now… 916-877-6904 Home About Services Long Term Care Plan ALW Application for RCFE’s Advocacy Assessment Client Assessment Form In-Home Care Independent Living Assisted Living/ Residential Care Residential Care with Dementia Senior Care Locator Resources Helpful Links Affordable Housing List Recommendations For Chronic Urinary Tract Infections Book Blog Media Videos Music Articles Newsletters Podcast Contact Senior Care Client Assessment Form Name* First NameLast Name Birthdate* /Month /DayYearDate Picker Icon Gender Age Height Weight Phone Number* Format: (000) 000-0000. Senior's Primary Diagnosis Please fill out the following questions according to senior's current condition. Check all that apply Cognitive/Behavior* AlertWander RiskPeriods of AgitationSigns of DepressionPeriods of ConfusionFollows DirectionsAnxietyAlzheimer's DiagnosisCombativeDementia DiagnosisSundowner'sVerbally AbusivePulmonary stenosisRequires RedirectingNoneOther Memory* Oriented to NameOriented to PlaceKnows Month/Year Short Term Memory* Appears OkayMild LossModerate LossSevere Loss Long Term Memory* Appears OkayModerate LossMild LossSevere Loss Mobility/Transfer* Independent1 Person assistCane2 Person AssistWalkerFall RiskWheelchair- Self PropelsPoor Safety awarenessWheelchair - Needs Assistance Neurological* No Problems NotedPast StrokeParkinson'sSeizure DisorderMultiple SclerosisRight Side WeaknessLeft Side WeaknessParalysisTia's (Mini Strokes)Other Respiratory* No ProblemsAsthmaShortness of BreathOxygen- 24/7PneumoniaOxygen - as neededCOPDOxygen- Self administeredInhaler/NebulizerOxygen - Needs HelpBronchitisOther Cardiovascular* No ProblemsEdemaCongestive Heart FailurePrior Heart AttackAnginaPrior BypassHypertension (High Blood Pressure)PacemakerAtrial FibrillationCoronary Atery diseaseOther Toileting* IndependentNeeds Assistance ToiletingContinentPerioddic AccidentsBriefs - During the dayBriefs - During the nightIncontinent - BladderIncontinent - DribbleIncontinent - BowelWears PadsNeeds Urinal Bedtime/Sleeping* Usually sleeps Through the NightIrregular HabitsInsomniaMay Wake to Use ToiletToilet 2-3 timesNeeds Assistance ToiletingUses Commode at Night Feeding* Feeds SelfDenturesNeeds Food CutAppetite - NormalEczemaAppetite LossSwallowing IssuesSpecial DietChewing IssuesFood AllergiesHas Own Teeth Bathing* IndependentHands-on Assist LightVerbal CueingHands-on Assist ModerateStand-by AssistHands-on Assist Total Grooming/Dressing* IndependentVerbal CueingStand-by AssistHands-on AssistLay out clothesAssist ShavingDental Assistance Hearing* AdequatePoorFair Vision* AdequateCataractsFairPast eye SurgeryPoorMacular DegenerationGlassesLegally BlindGlaucomaOther Diabetes* NoneControlled by DietSelf-Managed InsulinOral medicationNeeds Assistance with InsulinAssistance with MonitoringSelf-Monitoring Skin Care* Routine care - No issuesCurrent Wound Stage 1Ointment for SkinCurrent Wound Stage 2Current BruisesCurrent Wound Stage 3Bruises EasilyCurrent Wound Stage 4Dermal Issues Urinary/Ostomy* No IssuesPermanent CatheterAssistance with OstomySelf Managed FoleyAssist Emptying BagCurrent Urinary Tract InfectionTemporary CatheterSelf Managed OstomyChronic Urinary Tract Infections Other- Medical* ArthritisMedical Procedures PendingOsteoporosisFracturesOn HospiceNone Other- Not Medical* Smoker - Less than a pack/dayAlcohol Abuse - CurrentHistory of Drug AbuseSmoker - More than a pack/dayHistory of Alcohol AbuseNone Current Medications Any Dementia Behaviors i.e. Sleep disturbances. Agitation, Delusions, Hallucinations Senior's Marital Status* MarriedNever MarriedDivorcedWidowed Have Durable Power of Attorney for: Healthcare (Advanced Health Care Directive)FinancialObtainingConservator Responsible Party #1 Name, Address, Phone Number Responsible Party #2 Name, Address, Phone Number Senior's Veteran Status* Not a VeteranWidow(er) of a VeteranVeteran -Discharged other than HonorableSpouse of a VeteranVeteran-Discharged Honorably or Under Honorable Conditions Applied or in the process of applying for Veteran Aid & Attendance Benefit? YesNoNeed AssistanceWhat is the Aid & Attendance Benefit? Financial Information (Budget for Care) SSI onlyLong Term Care InsuranceAdequate for Assisted Living ($4,000 - $10,000/month)Adequate for Room & Board ($1,000 - $3,000/month) Senior's Social and Activity Interests Type of TV shows they like, activities they like doing, ie gardening, knitting, board games, puzzles, etc... Anything Else We Need to Know about the Senior Submit Should be Empty: HIPPA Guidelines Have a question? Need FREE help? We will contact you... Name(Required)Email In order to contact you, either Email or Phone is required. You may enter both.City or CountyPhoneMessageCAPTCHA Home About Services Long Term Care Plan ALW Application for RCFE’s Advocacy Assessment Client Assessment Form In-Home Care Independent Living Assisted Living/ Residential Care Residential Care with Dementia Senior Care Locator Resources Helpful Links Affordable Housing List Recommendations For Chronic Urinary Tract Infections Book Blog Media Videos Music Articles Newsletters Podcast Contact © 2013-2026 Senior Care of Sacramento 916-877-6904
