ADLS & IADLS
Client Assessment Form

Complete only the information you believe is required for us to provide personal support. If you have any questions, feel free to contact our Care Manager - Lynn Paltooram at (833) 779-2273.  Information gathered is used for assessment purposes only and data is not shared with any 3rd parties. 


Client Contact Information


Primary Physician


LHIN / CCAC Services


Covid-19 Screening

Does the client show any of the following symptoms?


YesNo
Feeling feverish
New loss of smell or taste
New or worsening cough
Shortness of breath or difficulty breathing
Muscle or body aches
Temperature equal to or more than 38°C
Chills and or headaches
Sore throat

Covid-19 Screening


Current Health Condition


Medical History

Please indicate only those conditions that impact the client's current health.

Medical & Assistive Devices


YesNo
Bed Rails
Briefs
Canes
Dentures
Glasses
YesNo
Hearing Aids
Lift Chair
Medic Alert
Rollator / Walker
Wheel Chair

Personal Support Services

Activities that Require Assistance


Emergency Contact Information


Invoices & Payment


Thank You!

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