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Personal Needs Questionnaire

Client Needs Questionnaire

Thank you for your interest in our personal care services. To help us better understand the care needs, please take a few minutes to fill out this questionnaire.

Step 1 of 7 - Client Personal Information

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Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Weight (in Pounds)*
Client Lives Alone?*
- Yes
- With spouse
- With other family
Gender*
- Male
- Female
- Non-Binary
Marital Status*
- Single
- Married
- Divorced
- Widowed

Medical Diagnosis*
Select all that apply
- Alzhiemer's
- COPD
- Dementia
- Heart
- Hospice
- Short Term Rehab
- Stroke
- Other (Please specify)
Medical Diagnosis - Other
COVID-19 Exposure*
Anybody in the household exposed to COVID-19?
- Yes
- No
COVID-19 Exposure Explanation
Ambulation Needs:*
Select all that apply
- Bed Bound
- Cane
- Gait Belt
- Hoyer Lift
- Motorized Chair
- Standby Assist
- Wheelchair
- Walker
- Independent
History of falls/Safety Issues
Functional Limitations*
- Hearing
- Speech
- Vision
- None
Functional Limitation Details

Activities of daily living*
Select ADLs that require assistance
- Bathing
- Drinking
- Dressing
- Feeding
- Grooming
- Skin Care
Toileting*
- Bathroom Assist
- Bedpan
- Bowel Incontinence
- Catheter
- Depends/Brief
- Urinal
- Urinary Incontinence
- No Assistance Needed
Medication Assistance*
Please note that our caregivers are not allowed to administer any kind of medication. We can only provider medication reminders
- Can self-administer medications with no assistance from others
- Can self-administer medications with assistance in remembering schedule
- Can self-administer medications with assistance in offering medications at prescribed times
- Cannot self-administer medications

Housekeeping Needs*
- Bed
- Laundry
- Dishes
- Bathroom
- Other
- N/A
Meals*
- Meal Preparation
- Tube Feeding
- Special Meal Requirements
- None
Special Meal Requirements
Transportation*
- Drives Independently
- Needs Driver
- Family Drives

Pets*
Pet care required?*
May be available for an extra fee
- Yes
- No

What activities does the client enjoy?
What does the client dislike?
Any additional preference?

Additional Comments
Signature*
Today's Date*
MM slash DD slash YYYY
Your relationship to the client*
Your Name*
First Last
Your Email*
Your Phone*
Your Address*
Street Address Address Line 2 City State ZIP Code

Contact

Email
info@lifefoundationhomecare.com
Phone
832.612.0472
Address
12808 W Airport Blvd, Ste 260L
Sugar Land, TX 77478

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About Life Foundation Home Care

Life Foundation Home Care is an award winning Texas based Home Care agency that provides quality and affordable in-home care in Greater Houston and Beaumont-Port Arthur area including Houston, Katy, Sugar Land, Hunters Creek Village, Stafford, Missouri City, Bellaire, Pearland, Richmond, Rosenberg, Pecan Grove, Fulshear, Sealy, The Woodlands, Cypress, Conroe, Kingwood, Baytown, Clear Lake, Beaumont, Port Arthur and other surrounding cities. Our qualified and experienced caregivers provide non-medical services that enable seniors to live a dignified life in the comfort of their homes

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