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Prescreen Form
Pre-screening of Potential Client Needs
Client Info
Date
*
Client Name
*
Diagnosis / Comments
Functional Assessment
Dressing
Independent
Independent with help
Aid of another person
Grooming
Independent
Independent with help
Aid in two or three areas
Mobility
Independent
Independent with walker/cane
Independent with wheelchair
Needs assist with wheelchair
Aid of one person
Potential for falls
Yes
No
Bathing
Independent
Supervision only
Aid in and out of shower
Aid in washing
Bowel / Bladder
Continent of urine and bowel
Independent with devices
Reminders
Device Type (if any)
Communication
Communicates well
Barriers to communication
Barriers include
Hearing
Hears well
Hearing impaired
Hearing aid in R ear
Hearing aid in L ear
No problem with corrective devices
Needs assist with corrective devices
Able to use phone
Yes
No
Sleep patterns
Sleeps well
Problem – describe
Sleep problem description
Eating
Independent
Slight help to arrange food
Feeds self with help
Needs feeding
Appetite
Good
Problem
Potential for choking
Appetite problem details
Psycho – Social Assessment
Memory
Memory intact
Mild memory problems
Mild memory problems exhibited by
Orientation
Oriented
Disoriented
Disoriented to
Time
Place
Person
Recreational Skills / Interests
Spiritual activities
Recreational outings
Watching T.V.
Other
Other (details)
Physical Assessment
Physical Health
No problems
Problem of
Problem details
Medications
No medications taken
Manages independently
Needs medications set up
Needs medication administration
Behavior
Not a problem
Occasional intervention required
Regular intervention required and responds to redirection
Other
Behavior (other details)
Mood and Temperament
Appropriate
Withdrawn
Sad, cries frequently
Anxious, restless
Suspicious
Irritable, angers easily
Other
Mood (other details)
Social Interaction
Socializes well
High social interest
Low social interest
Problem
Social interaction problem
Potential for Abuse/Neglect
No problem
Physical
Verbal
Financial
Self
Potentially Hazardous Activities
No problem
Drives car
Smokes
Scooter
Chemical use
Oxygen
Risk of elopement
Other
Hazards (other details)
Waivered Services
Client receives home and community based waivered services
Yes
No
Which waivered service?
EW
CADI
BI
Other
Other waiver (details)
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