ASAP Wellness Cares

Client Intake Form

Client Intake Form

    Client Information

    Full Name:

    Date of Birth:

    Gender:

    Phone Number:

    Email:

    Preferred Contact Method (Phone/Email):

    Address:

    Emergency Contact Information

    Full Name:

    Relationship to Client:

    Phone Number:

    Alternate Phone Number:

    Primary Care Physician Information

    Physician’s Name:

    Phone Number:

    Date of Last Visit:

    Address:

    Health and Medical Information

    Primary Diagnosis/Condition:

    Secondary Diagnosis/Conditions (if any):

    Allergies (food, medication, etc.):

    Medications (Please list name, dosage, and frequency):

    Mobility & Physical Needs

    Mobility Aid Used (Wheelchair, Walker, Cane, etc.):

    Level of Assistance Needed (None, Partial, Full):

    Special Accommodations Needed (Ramps, Grab Bars, etc.):

    Daily Living Assistance

    Personal Care Needs (Bathing, Dressing, Grooming):

    Meal Preparation & Feeding Assistance Required:

    Medication Reminders Needed:

    Light Housekeeping Assistance Required:

    Transportation Assistance Required:

    Companionship Needs:

    Scheduling and Availability

    Preferred Start Date of Services:

    Preferred Time of Day:

    Days of the Week for Service (check all that apply):

    Additional Information

    Any Other Relevant Information or Special Instructions:

    Consent and Agreement

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