Nurse Intake Form

Submit your completed Nurse Intake Form to begin working with BSHHA’s licensed care team. This form helps us match you with the right care assignments in Brooklyn, NY.

INITIAL INTAKE ASSESSMENT

CLIENT NAME(Required)

VISIT DATE

DUE DATE

VAU REP.(Required)

Phone(Required)

EFF. DATE:

MLTC REP:(Required)

Phone(Required)

CLIENT ADDRESS(Required)

Phone(Required)

LANGUAGE(Required)

S.S.#(Required)

SURPLUS(Required)

MEDICAID#(Required)

SEQ(Required)

MEDICARE #(Required)

COUNTRY OF ORIGIN(Required)

DATE OF BIRTH

HRS AUTH:(Required)

DAYS(Required)

DF(Required)

BILL HRS.(Required)

EMERGENCY CONTАСТ:

1. NAME(Required)

ADDRESS(Required)

Phone

ALT Phone

KEY

2. NAME(Required)

ADDRESS(Required)

Phone

ALT Phone

KEY

RELATION(Required)

AVAILABILITY(Required)

3) HAS CLIENT RECEIVED HCS IN THE PAST OR CURRENTLY RECEIVING:

IF YES: VENDOR NAME:(Required)

TEL. #

PRESENT AT INTERVIEW(Required)

SOURCE OF INFO.

PRESENT AT INTERVIEW(Required)

OTHERS IN HOUSEHOLD:

1) NAMЕ:

RELATION:

AGE:

2) NAMЕ:

RELATION:

AGE:

3) NAMЕ:

RELATION:

AGE:

If yes, who cares for pet

RELATION:

AGE:

Does anyone in the home require child care?

Yes

No

PETS:

Yes

No

If yes, who cares for pet

What kind of Pet?

Environment/Pose difficulty for tasks completion:

LIVE-IN AССОMODATION

Yes

No

SLEEPING

SPACE

PRIVACY

SMOKING IN THE HOME

ALCOHOL/RECREATIONAL DRUGS

RELIGION

DOCTORS/CLINIC

1) NAME:

SPECIALTY

ADDRESS:

Phone

2) NAME:

SPECIALTY

ADDRESS:

Phone

3) NAME:

SPECIALTY

ADDRESS:

Phone

PRIMARY HOSPITAL:

NEAREST

MD VISITS/HOW OFTEN:

DIET

ALLERGIES

WEIGHT

HEIGHT

PHARMACY

Phone

ADDRESS

AMBULETTE/CAR SERVICE

DIALYSIS

Yes

No

CENTER

PROGRAM

DIAGNOSIS

MOST RECENT HOSPITALIZATION:

CLIENT COMPLIANT:

HX OF SURGERIES:

PHYSICIAN HX: DX

HOSPITAL ADMITS:

CURRENT THERAPY:

ENDANGERING BEHAVIORS:

IMPAIRMENTS:

SPEECH

DOM HAND

OTHER

LE

CARDIAC

RESP

CONTINENCE: URINE

BOWEL

COGNITIVE

JUDGEMENT

ABLE TO LEARN

ABLE TO DIRECT

PREFERENCE: TIME OF RISING

BATH

BREAKFAST

LUNCH

DINNER

BED

AMBULATION

MEMORY

ANXIETY/DEPRESSION

DILUSIONS

HALUCIN

SUNDOWNERS

WANDERING

FALLS

WHO IS RESPONSIBLE FOR FINANCES

WHO IS RESPONSIBLE FOR GROCERIES

WHO IS RESPONSIBLE FOR GROCERIES

WHO OPENS DOOR

CAN CLIENT BE LEFT ALONE

VISION

HEARING

DME:

HAS

NEEDS

MEDS:

WHO MANAGES MEDS:

DISCUSS:

1) RN ROUTINE VISITS

2) COORDINATOR VISITS

3) CLOCK IN/OUT

4) RULES FOR KEYS

5) VALUABLES

6) BENEFIT CARD

7) LAUNDRY IN/OUT

8) ESCORT EXPENSE

9) PHONE TYPE LAUND/CELL

FIRE EXTINGUISHER

FIRE EXIT

SMOKE ALARM

CARBON MONAXIDE

CAPTCHA

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