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Pre-Admission Assessment Form
Url
SECTION A: SERVICE REQUIRED
Long-term
Short-term
Convalescence (Post-hospital care)
Senior Day Care
SECTION B: PERSON WHO NEEDS CARE INFORMATION
Age
*
Gender
*
Please select
Female
Male
SECTION C: CURRENT RESIDENCE INFORMATION
No formal or informal supports at home
Informal support (family/friends) at home
Formal support (home nursing/private caretaker) at home
Both formal and informal supports
At a nursing care facility
At Hospital
Nursing Care Facility
Hospital
Current Home Address
*
SECTION D: PHYSICAL CONDITION
Does this person wear diapers?
*
No
Yes
Does this person have wound?
*
No
Yes (Pressure sores, Injury, Deep abrasions, Puncture wounds, Animal bites, Others)
Does this person use catheter?
*
No
Yes
Does this person use nasogastric tube (NG tube)
*
No
Yes
Does this patient have a risk of fall?
*
No
Yes
Mobility
*
Dependent
Able to assist
Independent
1. Which of the following conditions are you (patient) currently being treated or have been treated for in the past (please check):
Heart disease / Murmur / Angina
Shortness of breathe
Eye disorder / Glaucoma
Diabetes
High cholesterol
Asthma
Seizures
Kidney / Bladder problems
High blood pressure
Lung problems / cough
Stroke
Liver problems / Hepatitis
Low blood pressure
Sinus problems
Headaches / Migraines
Arthritis
Heartburn (reflux)
Seasonal allergies
Neurological problems
Cancer
Anemia or blood problems
Tonsillitis
Depression / Anxiety
Ulcers/colitis
Swollen ankles
Ear problems
Psychiatric care
Thyroid problems
Other
Other patient conditions
Have the person who needs care diagnosed with Covid-19
Yes
No
If Yes, please provide the following info
Home quarantine date
Admission Date
Discharge Date
Is the person who needs care fully vaccinated against Covid-19
Fully vaccinated
Yes
No
If Yes, please provide the following info
Date of First Dose
Date of Second Dose
Type of Vaccine
eg. Pfizer, Sinovac, AstraZeneca (AZ) and etc
Section E: Contact Person
Name
*
Email
*
Contact No.
*
Relationship with people who needs care
*
