PAS Registration

Client Name*

Client Gender*

Male

Female

Client Date Of Birth*

Client Address*

Marital Status*

Married

Single

Widow

Language*

Height and Weight*

Authorized Person in Charge of Care (enter N/A if you are the client)*

Authorized Person in Charge of Care's Phone number (enter N/A if you are the client)*

General practitioners name:*

General practitioners phone:*

Current Living Situation*

Lives at home alone

Lives at home with family member/friend

Lives in public care facility

Lives in hospital/rehabilitation

Other

Mobility (select all that apply)*

No assistance

Cane

Walker

Wheelchair

Require lift equipment

Personal Care*

Bathing/Showering

Toileting

Dressing

Brushing hair

Trimming fingernails

Trimming toenails

Shaving

Applying cream

None or other (for other describe in additional details section at the end of this form)

Meals*

Eating

Preparing meals

Drinking

No assistance

Home Environment*

Walking

Going up stairs

Chair transfer

Bed transfer

Answer door

Answer phone

Walk indoors

Walk outdoors

No assistance

Other (describe in additional details section at the end of this form)

Housekeeping*

General surface cleaning

Cleaning bathrooms

Laundry

Changing sheets

Organizing

No assistance

Other (describe in additional details section at the end of this form)

Did client have one or more falls in the last 6 months?*

Yes

No

Is client taking one or more medications that my cause dizziness or loss of balance?*

Yes

No

Any recent changes in medication or functional status?*

Yes

No

Is client aware of objects in his/her immediate environment, and can describe what they are?*

Yes

No

Does client have hearing aids?*

Yes

No

Ability to hear conversations with ease?*

Yes

No

Does client require assistance or supervision when walking or transferring?*

Yes

No

Is client able to operate mobility aid safely?*

Yes

No

Does not apply to client (no mobility aids)

Does client need or require encouragement to walk/exercise?*

Yes

No

Can client get in/out of bed safely?*

Yes

No

Are stairs present in the home?*

Yes

No

Does client have an incontinence issue?*

Yes

No

Can client get on and off toilet safely?*

Yes

No

Overall level of fall risk:*

Low

Moderate

High

Verbal communication:*

Very good

Good

Some difficulty

Has difficulty

If communicating is difficult, how does the client express thoughts, feelings, likes and dislikes?*

Food and drink preferences:*

Is alcohol to drink permitted?*

Yes

No

If you answered Yes to alcohol drinks permitted, list restrictions:

Does client smoke?*

Yes

No

Does client have end-of-life directives in place?*

Yes

No

Current medical status (diagnosis made by a licensed medical professional)*

Dementia

Stroke

Diabetes

Macular Degeneration

Cancer

Parkinson's

MS-Multiple Sclerosis

Heart Disease

Arthritis

Other

Please list any details to the condition that may cause triggers or provide comfort for the client:*

Primary contacts of client:*

Does client need transportation provided by caregiver?*

Yes

No

Will caregiver be utilizing their own car to transport client?*

Yes

No

Transportation not required

Does client currently drive their own vehicle?*

Yes

No

Please specify any driving restrictions:

Client vehicle information (skip if transportation is NOT selected)

Client vehicle insurance information: (skip if transportation is NOT selected)

Does caregiver have permission to drive client's vehicle?*

Yes

No

N/A transportation not required

Is a parking permit paper, sticker, key or electronic device needed when parking?

Additional Comments or Concerns:

Signature of Client or authorized person in charge of care*

Client Online Registration