Free Home Care Assessment Form Template

Home Care Client Assessment Form

Non-medical home care. This form is for planning care and support services only. It is not a medical or skilled nursing assessment.

Date of assessment: __________________  Assessor name: __________________

1. Client Demographics

2. Emergency Contacts and Responsible Party

Emergency contact 1

Emergency contact 2

Responsible party (person who handles decisions or payment, if different from client)

3. Medical Background

For care planning only. Record what the client or family reports. Do not diagnose.

Conditions and diagnoses (as reported by client or family)

Prognosis or expected changes (in the family’s words, if shared)

Allergies (food, medication, environmental)

[ ] No known allergies

Current medications (copy exactly from labels or med list)

Who currently manages medications? __________________________

4. Functional Limitations

Mobility aids in use: [ ] Cane  [ ] Walker  [ ] Wheelchair  [ ] Rollator  [ ] None  [ ] Other: __________

5. Activities of Daily Living (ADLs)

Rate each based on what you observe and what the client tells you.

6. Instrumental Activities of Daily Living (IADLs)

7. Home Safety Observations

Other safety notes:

8. Caregiver Match Preferences

Mark whether each preference is Required or Preferred.

Other preferences:

9. Care Goals

In the client’s or family’s own words. Write what they say.

10. Proposed Schedule

Notes on timing or flexibility:

11. Signatures

How to Use This Form

This form is built to be filled out in one sitting during a first in-home visit, usually in about 45 minutes. Print it and bring a clipboard and two pens. You do not need to complete the sections in order. Most assessors start with demographics and emergency contacts while the client settles in, then move into the medical and daily living questions once there is a bit of rapport.

For the medical section, copy medications straight from the pill bottles or the client’s med list. Do not rely on memory, and do not correct or interpret what you see. Your job is to record, not to diagnose.

The ADL and IADL tables are the heart of the assessment. “Independent” means the person does the task safely on their own. “Requires Assistance” means they need help, standby support, or reminding. “Dependent” means someone else does it for them. Use the notes column freely, since that detail is what helps you match the right caregiver and build a realistic schedule.

Walk through the home for the safety section rather than asking from the couch. Look at the bathroom, the stairs, and the path the client takes most often.

Capture care goals in the family’s own words, even if they are informal. “I want Mom to stay in her house” tells you more than a checkbox.

Finish by reviewing the proposed schedule out loud and getting signatures. Keep the signed original in the client file and give the family a copy.

This form supports care planning and does not meet any specific state licensing, Medicaid, or accreditation requirement. Requirements vary by state, so check your local rules.