American Healthcare Services, Inc. | FREE Online Care Assessment

FREE Online Care Assessment

*Client First Name:

*Client Last Name:

*Client Address:

*Client City:

*Email:

*Type of Sessions Needed(Day/Week):
  Day(s)  Week

*Hours Per Session:

*Next of Kin/Friend:

*Relationship:

*City:

*State:

*Zip Code:

*Telephone number:

Services Needed?:

MPS/DDD:(optional)  Yes  No

* Program Participation:  Yes  No

* Personal Care:
Bathing
Hair Care
Skin Care
Nail Care

* Elimination (Toileting):  Specialized  Normal

* Personal Hygiene:  Yes  No

* Light Housekeeping:  Yes  No

* Grocery Shopping w/ Client:  Yes  No

* Bedding:  Linen Changing  Making

* Laundry:  In house?  Out of house?

* Meal Preparation:  Breakfast  Lunch  Dinner  All

Referred By:

Providing Quality Home Care with Dignity