Patient's First Name:

Patient's Last Name:

Have they received home care services before?

Yes    No

If so, when?:

Screening - Does Client:

Use Telephone?

Yes    No

Get out of bed unassisted?

Yes    No

Walk unassisted?

Yes    No

Operate a motor vehicle?

Yes    No

Shop for essentials?

Yes    No

Handle money/pay bills?

Yes    No

Prepare Meals?

Yes    No

Eat Unassisted?

Yes    No

Do routine housework?

Yes    No

Do laundry?

Yes    No

Dress and undress self?

Yes    No

Shower/Bathe/Groom self?

Yes    No

Get to toilet in time?

Yes    No

See physician frequently?

Yes    No

Follow medical directions?

Yes    No

Have prescribed medications?

Yes    No

Have diabetes?

Yes    No

Receive home health care?

Yes    No

Have a physician?

Yes    No

Have physician-ordered therapies?

Yes    No

Have adequate informal support?

Yes    No

Seem confused?

Yes    No

Have ability to share in cost of care?

Yes    No