STEAD CARE QUICK ONLINE ASSESSMENT

STEAD SOCIAL CARE CLIENT QUICK ONLINE ASSESMENT & MEDICAL QUESTIONAIRE FORM

Please complete the client quick assessment and medical form for the clients in question so as to help us ensure that we provide you with the right care.

Is the Assessment for you?

Yes
No

Others (please specify)

Client First Name*

Client Surname*

Client Address*

Current Location

Hospital
Clinic
Home

Client Age*

Client Gender

Male
Female

Phone No*

E-mail Address*

Are you currently on any Medication

Yes
No

If yes please indicate

Any Pre Existing Medical Conditions?

Yes
No

If Yes kndly Indicate

Blood Pressure
Diabetes
Arthritis
Stroke
Heart Disease
Dementia
Epilepsy
Pneumonia
Cardiovascular Diseases
Hearing Loss
Blindness
Cancer
Allergies
Non Allergies
Cataracts
Paralysis
Hypertension
Chronic Liver Disease
Any Operational or Surgical Procedures

Movement/DISABILITIES:- State any condition that restricts you from moving from one point to another*

Are you currently on my Medication?*

Blindness/Sight Implant?

Yes
No

Hearing Implant?

Yes
No

Physical Disability?

Yes
No

Nursed in Bed (Bedridden)

Yes
No

Are you currently using one of the following?

Wheel Chair
Zimmer Frame
Walking Stick
Commode (Mobile Toilet)

Distance you can walk without help or assistance

Bed to Chair
Bed to the Bathroom
Bed to Kitchen
10 feet
20 feet
30 feet
35 or more

Home
About
Our Services
Testimonials
Contact
STEAD CARE QUICK ONLINE ASSESSMENT

Accessibility