Emmaus Care
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*Assessment Form*
Name:
Address
City
zip code
Phone
Email Address:
Weight of the client in lbs
Name of the client
Gender
Male
Female
Medications
Select
Yes
No
Some Times
Bathing or showering
Select
Yes
No
Some Times
Toileting, Incontinence
Select
Yes
No
Some Times
Current living situation
Select
Home alone
Lives with family
Assisted living facility
Nursing home
Hospital
Walking ability
Select
Independent
with cane
with walker
wheelchair
bedridden
Memory loss
Select
No
Some times
Frequently
Alzheimer diagnosis
Dementia diagnosis
Your relation to the client
Select
Spouse
Daughter/Son
Relative
Friend
Social worker
home
