Orientation
The following questions are orientation questions to get a sense of mentation ability for safety purposes.

Orientation · Person
Do they know who they are and who their family members are?

Orientation · Place
Do they know where they are? Can they identify the building, city, and state?

Orientation · Time
Do they know their date of birth, the current year, day of the week, and date?

Orientation · Situation
Do they understand the purpose of the evaluation and what is happening around them?

Medications
Please list prescribed medications

Medical History
Please list medical history (Ex: Hypertension, diabetes, stroke, etc.)

Medical History
If you are capable of uploading History and Physical, physical therapy, or speech therapy notes, you can do so.
Photos of the files are also an option. This step is optional. Accepted files: PDF, DOC, JPG, or PNG up to 10MB.

Mobility
How do they ambulate?
WalkerWheelchairBedboundOther

Mobility
Can they turn themselves in bed without help?
YesNoOther

Incontinence
Are they incontinent (diapers, depends, etc)?
YesNoOther

Wounds
Are there any wounds or wound care needs (dressing changes, skin breakdown)?
YesNoOther

Oxygen
Are they prescribed oxygen?
YesNoOther

Almost done
If there is any other information you would like us to know, please share it with us here.
Optional

Your contact details
How can we reach you?
We will use this to discuss your quote and schedule a tour.