Phone:832.612.0472
Email:info@lifefoundationhomecare.com
Hours of Operation:Monday-Friday 9:00am to 5:00pm

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Personal Needs Questionnaire

Client Needs Questionnaire

Thank you for your interest in our personal care services. To help us better understand the care needs, please take a few minutes to fill out this questionnaire.

Step 1 of 7 - Client Personal Information

14%

Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Weight (in Pounds)*
Client Lives Alone?*
- Yes
- With spouse
- With other family
Gender*
- Male
- Female
- Non-Binary
Marital Status*
- Single
- Married
- Divorced
- Widowed

Medical Diagnosis*
Select all that apply
- Alzhiemer's
- COPD
- Dementia
- Heart
- Hospice
- Short Term Rehab
- Stroke
- Other (Please specify)
Medical Diagnosis - Other
COVID-19 Exposure*
Anybody in the household exposed to COVID-19?
- Yes
- No
COVID-19 Exposure Explanation
Ambulation Needs:*
Select all that apply
- Bed Bound
- Cane
- Gait Belt
- Hoyer Lift
- Motorized Chair
- Standby Assist
- Wheelchair
- Walker
- Independent
History of falls/Safety Issues
Functional Limitations*
- Hearing
- Speech
- Vision
- None
Functional Limitation Details

Activities of daily living*
Select ADLs that require assistance
- Bathing
- Drinking
- Dressing
- Feeding
- Grooming
- Skin Care
Toileting*
- Bathroom Assist
- Bedpan
- Bowel Incontinence
- Catheter
- Depends/Brief
- Urinal
- Urinary Incontinence
- No Assistance Needed
Medication Assistance*
Please note that our caregivers are not allowed to administer any kind of medication. We can only provider medication reminders
- Can self-administer medications with no assistance from others
- Can self-administer medications with assistance in remembering schedule
- Can self-administer medications with assistance in offering medications at prescribed times
- Cannot self-administer medications

Housekeeping Needs*
- Bed
- Laundry
- Dishes
- Bathroom
- Other
- N/A
Meals*
- Meal Preparation
- Tube Feeding
- Special Meal Requirements
- None
Special Meal Requirements
Transportation*
- Drives Independently
- Needs Driver
- Family Drives

Pets*
Pet care required?*
May be available for an extra fee
- Yes
- No

What activities does the client enjoy?
What does the client dislike?
Any additional preference?

Additional Comments
Signature*
Today's Date*
MM slash DD slash YYYY
Your relationship to the client*
Your Name*
First Last
Your Email*
Your Phone*
Your Address*
Street Address Address Line 2 City State ZIP Code

About Us

Life Foundation Home Care is an award winning Texas based Home Care agency that provides quality and affordable in-home care in Greater Houston, Dallas-Fort Worth and Beaumont-Port Arthur area including Houston, Katy, Sugar Land, Stafford, Missouri City, Bellaire, Pearland, Richmond, Rosenberg ... Read More

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12808 W Airport Blvd, Ste 260L Sugar Land, TX 77478
832.612.0472
info@lifefoundationhomecare.com

Dallas Office
5301 Alpha Road, Suite 80 - 57, Dallas, TX 75240
214.764.9878

San Antonio Office
7550 W IH-10 Suite 800 San Antonio, TX 78229
210.571.0120

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