Client Information Profile Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Client Lives Alone? * Yes No Phone * (###) ### #### Marital Status: * Single Married Divorced Widowed Date of Birth * Allergies: Medical Power of Attorney * Contact Information Primary Contact Secondary Contact Family, Friends, etc * Family, Friends, etc Family, Friends, etc Pets, Levels in home, Stairs, Interests Health Provider Contact Information * Primary Physician Doctor's Address, Phone, Fax, Email, Other Information Other Physicians/Healthcare providers (Dentist, Pharmacist, Optometrist, Optician, Podiatrist, Chiropractor) Other Physicians/Healthcare providers (Dentist, Pharmacist, Optometrist, Optician, Podiatrist, Chiropractor) Other Physicians/Healthcare providers (Dentist, Pharmacist, Optometrist, Optician, Podiatrist, Chiropractor) Miscellaneous Contact Information Service, Contact, Phone Service, Contact, Phone Service, Contact, Phone Healthcare Insurance/Private Coverage Information * Long term care Supplemental Health Insurance Plan Home Services Profile Light Housekeeping Dusting Vacuum Damp Mop Change Bedding Bathroom General Tidying Other Notes: Laundry Wash Dry Iron Fold Put Away Notes: Meal Preparation Meal Planning Preparation Cooking Serving Wash Dishes Other Notes: Outdoor Maintenance Gardening Lawn Snow Other Notes: Pet Care Dog Cat Fish Other Notes: Personal Care Medicine Reminder Dressing Bathing Hairdressing Makeup Washing Shaving Nail Care Other Notes: Attendant Shopping Appointments Church Friends Activities Other Notes: Other Service: Notes: Housekeeping Notes: Living Room Dining Room Dining Room Kitchen Family Room Master Bed Ensuite Bedroom 1 Bedroom 2 Bedroom 3 Bathroom 1 Bathroom 2 Bathroom 3 Basement Other Other Dietary Profile Food Allergies Yes No Help with feeding required Self Assist Total BREAKFAST * LUNCH * SUPPER * SNACKS * Daily Routine * MONDAY * TUESDAY * WEDNESDAY * THURSDAY * FRIDAY * SATURDAY * SUNDAY Monthly Routine/Appts * WEEK 1 * WEEK 2 * WEEK 3 * WEEK 4 * WEEK 5 Activity Thank you! We appreciate you taking the time to share your details with us. Our team will review your information and reach out if any further details are needed.
