Care Consultation Form

647-946-5324
info@prokare.ca

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CLIENT INTAKE

First Name

Last Name

Gender

Phone

Email Address

Birthdate

Emergency Contact

First Name

Last Name

Phone

Email Address

Relationship

Does the Client have POA?

Does Anyone Else Live with the Client?

What are the Clients Priorities? *

Quality of LifeAllow family yo be family instead of caregiverSafetyOversightCompanionshipStay in HomeRecover from Surgery/Hospitalization Comfort Measures/Palliative CareOther

You can select more than one

What are the Family/Loved ones' Priorities?

Quality of LifeAllow family yo be family instead of caregiverSafetyOversightCompanionshipStay in HomeRecover from Surgery/Hospitalization Comfort Measures/Palliative CareOther

You can select more than one

Is there a Do Not Resuscitate in Place for the Client?

Make Each Day Count

Help us get to know you or your loved ones better so we can provide more than just task- based care

Tell us something you used to love doing that you haven't done in a while?

Please tell us how can we create a better life at home, and please don't leave anything out?

Medical History

Past Medical History (Select all that apply)

Click to SelectDiabetesHigh Blood PressureHigh Cholesterol Hypothyroidism GoitorCancerLeukemia PsoriasisAnginaHeart ProblemsHeart MurmurPneumonia Pulmonary EmbolismAsthmaEmphysema StrokeEpilepsyCataractsKidney DiseaseKidney StonesCorbin's DiseaseColitisAnemiaJaundiceHepatitis Stomach or Peptic UlcerRheumatic FeverTuberculosis HIV/AIDSSexually Transmitted DiseaseUsual BleedingAnxiety Depression

You can select more than one

What did you use to do for work?

Allergies

Are there any pets in the House?

Route

Does the client smoke or live with a smoker?

Current Medications

Dose

Dosage Type

Medication Type

Start Date

Time Instruction

Current Medical DiagnosisPlease include details like Description and Date of Diagnosis

Past Surgeries/Treatments Details

Past Hospitalization Details

Care and Precautions

Memory Care *

Client Wears glasses *

Client Wears Hearing Aids *

Toileting *

Personal Care *

Precautions (Select All that Apply *

Activities Permitted *

Ambulation/Falls Risk

Recent Falls *

Ambulation *

Transferring *

Meals and Housekeeping

Specific Diet to be Followed

Thickened Liquids Cardiac Diet ( Low Sodium, Low Fat)Diabetic Diet Renal Diet

Meal Preparation *

Food Preference - Breakfast

Food Preference - Lunch

Food Preference - Dinner

Food Preference - Snack/Dessert

Housekeeping Requested

Specify Location/Frequency

Physician and Pharmacy Contact Information

Name and Contact Information

Name

Phone

Email Address

Physician and Pharmacy Contact Information

Name and Contact Information

Name

Phone

Email Address

Durable Medical Equipment (DME)

What medical equipment is currently in use by the client?

Accessible Ramp Adjustable BedBath BoardBath ChairCaneCar Mobility LiftCatheter SuppliesCrutchesDressing SuppliesFeeding Aid/SuppliesFeeding PumpGrab BarsHome Care Bed (Hospital Bed)Ice PacksIrrigation SuppliesIV PolesIV SuppliesLift ChairLift: ManualLift: HydraulicO2 Masks02 Nasal Cannula02 Tubing02 ConcentratorOstomyOxygenROHO Mattress Raised Toilet SeatScooterStair: LiftStationary CommodeSuction MachineTracheostomy SuppliesTransfer: Ceiling Lift Transfer: Standing LiftTransfer BeltTransfer PoleTransfer TurntableWalker RollingWalker StationaryWheelchair

Notes/Additional Information

Comments

CONTACT

Email: info@prokare.ca

Corporate Office: 647-243-4419
Booking: 647-513-2707
Fax: 647-493-9042
Toll-free 1-833-387-7449

ADDRESS

Suite 202- 120 Matheson Boulevard East, MIssissauga Ontario, Canada L4Z 1X1

WORKING HOURS

MONDAY - FRIDAY
9:00 AM - 5:00 PM

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