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Personal Information

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Date of Birth *

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Address *

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City

State / Province / Region

Postal Code

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Preferred Method of Contact *

• Phone
• Email
• Mail

Emergency Contact Information

Name *

First

Last

Relationship to Client:

Emergency Contact Phone Number *

Emergency Contact Email Address:

Health Information

Primary Care Physician Name:

First

Last

Primary Care Physician Phone Number

Current Health Conditions (Please list all)

Current Medications (Please list all):

Allergies (Please list all):

Do you have any mobility issues? *YesYesNo

if yes, please describe

Do you use any assistive DevicesYesYesNo

If yes, please specify ( eg, Walker, Wheelchair etc):

Care Needs Assessment

What type of care are you seeking? (Check all that apply)

• Personal Care (Bathing, Dressing, Grooming)
• Companionship
• Meal Preparation
• Medication Reminders
• Housekeeping
• Transportation
• Dementia/Alzheimer’s Care
• Other

If Others, please specify

Preferred Care Schedule:

• Full-Time
• Part-Time
• Live-In
• As Needed

Preferred Days and TImes for Care:

Do you have any specific care instructions or preferencesYesYesNo

If Yes, please describe:

Living Situation

Do you live alone?YesYesNo

If no, who do you live with?

Describe your home environment (eg, house, apartment, assisted living):

Are there any pets in the home?YesYesNo

if yes, please describe

Additional Information:

How did you hear about Sewa Senior Care?

Do you have any additional information or comments that will help us provide better care?

Insurance Information:

Do you have long-term care insurance?YesYesNo

If yes, please provide the insurance company name and policy number:

If no or not sure, do you have medicaid or medicare?Yes – MedicaidYes – MedicaidYes – MedicareNo

If No, do you want us to apply for your medicaid or medicare?YesYesNo

Consent and Agreement

I consent to the collection and use of my personal information by Sewa Senior Care as necessary to provide care. *YesYesNo

I agree to the terms and conditions of service provided by Sewa Senior Care. *YesYesNo

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