New Client Assessments
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    Choose Most Relevant Answers:

    1. Allergies:

    2. Allergy/ Sensitivities:

    3. Alcohol:

    4. Alcohol Consumption:

    5. Appetite:

    6. Assistive Devices:

    7. Assistive Devices:

    8. Behavioral:

    9. Bladder:

    10. Blood Pressure:

    11. Body Limitations:

    12. Body Mass:

    13. Body Swellings:

    14. Bowels:

    15. Bowel Issues:

    16. Bowel Colors:

    17. Breathing Patterns:

    18. Caffeinated Beverages:

    19. Cognition:

    20. Cold:

    21. Communication:

    22. Coordination:

    23. Cough:

    24. Culture Factors:

    25. Diabetic:

    26. Diet:

    27. Diet:

    28. Dizziness:

    29. Ears:

    30. Eyes:

    31. Feedings:

    32. Feedings Hazards:

    33. Financial Management:

    34. Fluid Intake:

    35. Gastrointestinal:

    36. Hair Issues:

    37. Headaches:

    38. Hearing Impairments:

    39. Housing:

    40. Illicit Drugs:

    41. Illicit Drugs Frequency:

    42. Inappropriateness:

    43. Irregular Heartbeat:

    44. Judgement:

    45. Literacy:

    46. Loss of Balance:

    47. Memory:

    48. Mental Behaviors:

    49. Mental Health History:

    50. Mood:

    51. Mood Thoughts:

    52. Muscular Issues:

    53. Numbness:

    54. Orientation:

    55. Pain:

    56. Pain Causes:

    57. Pain Description:

    58. Pain Location:

    59. Pain Management:

    60. Perceptions:

    61. Prosthesis:

    62. Psychiatric Treatment:

    63. Religious Factors:

    64. Risk:

    65. Skeletal Issues:

    66. Skin Condition:

    67. Skin Issues:

    68. Sleeping Habits:

    69. Smoking Habits:

    70. Speech:

    71. Speech Method:

    72. Suicidal Thoughts:

    73. Teeth:

    74. Teeth/Tooth Issues:

    75. Transferring:

    76. Urination:

    77. Urine Color:

    78. Vision:

    79. Vision Issues:

    80. Wound(s):

    81. Other:

    Client Signature:

    Caregiver's Printed Name:

    Caregiver's Signature:

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