Prescreen Form – COMMUNITY CONNECT HOME CARE LLC

Date *

Client Name *

Diagnosis / Comments

Dressing

Independent Independent with help Aid of another person

Grooming

Independent Independent with help Aid in two or three areas

Mobility

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

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

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 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

Mood (other details)

Social Interaction

Socializes well High social interest Low social interest Problem

Social interaction problem

Potential for Abuse/Neglect

Potentially Hazardous Activities

Hazards (other details)

Client receives home and community based waivered services

Yes No

Which waivered service?

EW CADI BI Other

Other waiver (details)

Community

Pre-screening of Potential Client Needs