Health Assessment | Victorian Order of Nurses Middlesex Elgin

23 February 2012

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We would like to help you receive the care that you and your family deserve. To help us provide you with our best service please complete the following form - there is no obligation of service.

The information will be sent to the Manager of Homecare who will contact you within 48 hours. If you require assistance before this please call 519-659-2273.

* Indicates required field

Contact Information

Name: *

Address: *

City: *

Province: *

Postal code: *

Phone: *

Alt Phone:

Email:

I would like care for

Other (Specify):

His/Her age:

You can contact me

Morning

Afternoon

Evening

Anytime

Care would be required

Immediately

Between one week and three weeks

Within one week

Three weeks or more

Other (Specify):

Currently the support system involves

Living with family/friends

Living alone, but family/friends live nearby

Living alone, family/friends live out of town but visit often

Living alone with no family/friends who visit

Other (Specify):

The mobility of the person requiring care

Independently mobile

Struggles to walk upstairs

Uses a cane or walker

Requires assistance whenever moving from place to place.

Other (Specify):

The housekeeping services that would be required would include

(check all that apply)

Other (Specify):

The personal support services that would be required would include

(check all that apply)

Assistance getting dressed or undressed

Assistance with bathing and personal grooming

Assistance using the bathroom

Assistance eating meals

No assistance is required

Other (Specify):

What are your expectations of VON nursing staff?

(check all that apply)

Medication management

Health education - for client and/or caregiver

Would care

Therapy (various - contact for more details)

Diabetes management

IV management

Other (Specify):

The current number of prescribed medications the person is taking is

Present health conditions include

(check all that apply)

Other (Specify):

Authorization

The information provided in the Health Assessment is strictly confidential and wil be used only for the administration of this request of information and for any future service being provided. Your completion of this application form authorizes VON to contact you for more information.

Agree: *

I Agree

I’ve been coming to the exercise classes every Monday and Friday for about a month now, and I just want to let you know how much I love them.

- SMART Program Client