Pre Care Assessment
Pre-Care Assessment
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Name of Person Completing this Form? *
Phone Number of Person Completing Form? *
Email Address *
Name of Person Needing Care *
Age *
Phone Number for Potential Client *
Address for Potential Client *
Do they have an Advanced Directive or completed POLST? *
Required
Are they their own guardian? *
Required
Do they live alone? *
Are they a Veteran? *
Do they have:  *
Required
Doctor(s) Contact Information: *
Past Profession: *
What areas of care assistance would you like (Check all the apply): *
Required
How is her/his hearing? *
Required
How is her/his vision? *
Required
How is her/his Speech? *
Required
Select All That Apply: *
Required
Any medication or food allergies? *
Wears briefs? *
Required
Incontinent of: *
Required
Does she/he have: *
Required
Select All That Apply: *
Required
Currently Receiving Services From:

 *
Required
Name and Contact Information for any of the above listed services:
How did you hear about us?  *
Thank you!
Thank you for taking the time to complete this Pre-Assessment. We will call you to follow up within the next 1-2 business days. If you have any questions, please call the Agency number at 503-396-0830 Monday - Friday between 8:00 am - 4:30 pm. We look forward to speaking to you soon!
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