Home Health Aide Assessment Form

Home Health Aide Assessment Form — Form Fields

This healthcare template includes 11 fields. Evaluate patient needs and home environment for assignment of appropriate home health aide services. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Patient Address (text, required)
• Emergency Contact Name (text, required)
• Emergency Contact Phone (text, required)
• Primary Diagnosis (dropdown selection, required) — options: Post-Surgical Recovery, Chronic Illness, Mobility Impairment, Neurological Condition, Cognitive Decline, Injury Recovery, Other
• Assistance Needed With (checkboxes, required) — options: Bathing, Dressing, Meal Preparation, Medication Reminders, Light Housekeeping, Transportation, Companionship, Wound Care
• Hours of Care Needed Per Week (dropdown selection, required) — options: Under 10 hours, 10-20 hours, 20-30 hours, 30-40 hours, 40+ hours, Live-In Care
• Does the Patient Live Alone? (multiple choice, required) — options: Yes, No
• Is the Home Wheelchair Accessible? (multiple choice, required) — options: Yes, No, Partially
• Additional Notes on Patient Needs or Home Environment (long text, optional)