Bee Well Elder Care Services

60 Poplar Street, Garden City, NY 11530 • Phone (516) 294-8094 • Fax (516) 294-1880

 

FAMILY QUESTIONNAIRE

It is often helpful to obtain information from a family member prior to seeing a client.

CLIENT INFORMATION

Your Name
Date
I would like
assistance for my:		 Mother       Father       Both
Other (specify)
His/Her/Their Name(s):
Address
City
State
Zip Code
Describe type of
living environment

Phone Number
Date of Birth
Social Security #
Insurance
Ethnic, racial or
cultural background
Religion
Marital Status

 

Pertinent Information

Hospital Preferred
Health Care Proxy
Power of Attorney
Living Will

 

Identification of Needs

Please detail your major concerns for your family member and specifically identify the type of assistance you seek.

FAMILY INFORMATION

Relatives of person needing assistance

Name
Relationship
Address
City
State
Zip Code
Phone
Business Phone
Email Address

 

Name
Relationship
Address
City
State
Zip Code
Phone
Business Phone
Email Address

 

Name
Relationship
Address
City
State
Zip Code
Phone
Business Phone
Email Address

MEDICAL INFORMATION

Describe the most significant health problem(s), medications and treatments:

Medical Problem(s)

Recent Hospitalizations or Rehabiliations (Specify)

Memory, Orientation and Judgment
If any memory problems exist, how disabling are they? Does your relative recognize you, the time, his/her location? Does s/he make sense most of the time? Has there been any recent long-term memory loss? Would you rate memory problems as mild, moderate, or severe? Is there a medical diagnosis and current treatment? Are you concerned about the individual being left alone?

Emotional Health
Is your relative as dependent, anxious, agitated, withdrawn, content, lonely, or other? Are you concerned about any recent changes in behavior or sense of well being? Are there any concerns about depression?

Pertinent Information

Who will take ongoing responsibility for talking with Care Manager?

Who will be responsible for payment of services provided by Bee Well Elder Care?

Additional Comments: