Client Questionnaire

	4408 North Miller Road Suite #103 Scottsdale, Arizona 85251 Phone: (480) 951-4083 Fax: (480) 951-4023
Non-Medical "Angels on Assignment" in Your Home

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Client Questionnaire

Name:
Address:
Phone:
Closest Cross Streets:
Nature of Illness:

If hourly, check hours desired

If live-in, check days desired

	None	Live-in	Hourly Start Finish
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Directions to Client's Home:

Client's Personal Information

Client's Age:
Date Of Birth:
Gender:
Personality:
Tobacco User:	yes no

Vision:	Poor	Good	Excellent
Hearing:	Poor	Good	Excellent
Speech:	Poor	Good	Excellent

Mental Status:
Oxygen:
Continence:
Ambulation:
Pets:
Other Medical Conditions:

Please check the Appropriate Box that Applies

	Assist With	Assistance Not Necessary
Ambulation:
Bathing:
Toileting:
Dressing:
Eating:
Food Preparation:
Med Reminders:
Transportation:
General Housekeeping:
Laundry:
Spring Cleaning :
Mobility / In & Out of Bed:
Hospital Recovery:
Massage Therapy:
Money Management:
Lunch & Movie Friend:
Friendly Companionship:
Grocery Shopping:

Additional Comments:

Responsible Party

Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
Bill To:	Client Patient
Form Filled Out By:
Return Email:
Date:

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