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Referral Form
Home
About
Services
Skilled Nursing Services
Therapy Services
Post-Hospital & Post-Surgical Transitional Care
Disease-Specific Skilled Care
Fall Risk & Home Safety Assessments
Home Health Aide
Companion & Supportive Care
Respite Care Services
Veteran Home Health Services
Specialty Programs
How to Pay
Training Programs
Home Health Aide (HHA) Training
Xalt Academy
Membership
Resources
FAQ’s
Contact
Service Areas
Careers
Forms
Referral Form
Client In-Take
Form
Complete our client intake form to begin personalized home healthcare services with XALT HEALTHCARE LLC. This process helps us understand your needs and coordinate care efficiently in Wellington, FL.
"
*
" indicates required fields
Step
1
of
5
20%
X/Twitter
This field is for validation purposes and should be left unchanged.
Date of Evaluation:
*
MM slash DD slash YYYY
DEMOGRAPHIC INFORMATION
Full Name
*
First Name:
Middle Name:
Last Name:
Your Address
*
Street Address:
Apartment/Unit (if applicable):
City:
State:
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code:
Phone Number:
*
Date of Birth:
*
MM slash DD slash YYYY
Age:
Email:
*
Gender:
*
Male
Female
Who is your primary care provider?
*
Email:
Address:
*
Phone Number:
*
Fax Number:
May we contact your physician?
*
Yes
No
PRESENTING PROBLEM
Please briefly describe what problem(s) with thinking you are experiencing:
Please indicate if you are independent or need help with any of the following.
Task
Need Help
Feeding yourself
Feeding yourself Yes/No
Yes
No
Driving
Driving Yes/No
Yes
No
Incontinence
Incontinence Yes/No
Yes
No
Bathing
Bathing Yes/No
Yes
No
Dressing
Dressing Yes/No
Yes
No
Transferring
Transferring Yes/No
Yes
No
Homemaking
Homemaking Yes/No
Yes
No
Ambulation
Ambulation Yes/No
Yes
No
Meal Prep
Meal Prep Yes/No
Yes
No
Med Reminders
Med Reminders Yes/No
Yes
No
Do you receive help in your home (e.g. family member, paid home health worker)?
Yes
No
How many days per week?
How many hours per day?
Who Helps?
MEDICAL HISTORY
Eye and Ear Problems
Heart Problems
Cataracts
Yes
No
Heart attack
Yes
No
Glaucoma
Yes
No
High Blood Pressure
Yes
No
Macular Degeneration
Yes
No
Heart Failure
Yes
No
Hearing Loss
Yes
No
Irregular Heartbeats (arrhythmia)
Yes
No
Do you use hearing aids?
Yes
No
Atrial Fibrillation
Yes
No
Do you utilize corrective lenses?
Yes
No
Aortic Stenosis
Yes
No
Other:
Other:
Lung/Pulmonary Problems
Bone and Joint Problems
Asthma
Yes
No
Gout
Yes
No
Emphysema
Yes
No
Osteoporosis
Yes
No
COPD
Yes
No
Fracture
Yes
No
Bronchitis
Yes
No
Other:
Other:
Metabolic/Endocrine Problems
Urinary and Kidney Tract Problems
Diabetes
Yes
No
Kidney Disease
Yes
No
Hyperthyroid/High Thyroid
Yes
No
Prostate Disease
Yes
No
Hypothyroid/Low Thyroid
Yes
No
Frequent Bladder Infections/UTI
Yes
No
Pituitary Gland Tumor
Yes
No
Other:
Hashimoto’s Disease
Yes
No
Other:
Neurological Conditions
Dementia
Yes
No
Huntington’s Disease
Yes
No
Type Identified:
Stroke
Yes
No
Toxin Exposure
Yes
No
Date
MM slash DD slash YYYY
Type:
Date:
MM slash DD slash YYYY
Epilepsy/ Instances of Seizures
Yes
No
Head Injury
Yes
No
Number of Injuries:
Date of Injury:
MM slash DD slash YYYY
Parkinson’s Disease
Yes
No
Other:
Gastrointestinal Problems
Other Health Conditions
Ulcers
Yes
No
Allergies
Yes
No
Diverticulitis
Yes
No
High Cholesterol
Yes
No
Heartburn
Yes
No
Sleep Apnea
Yes
No
Irritable Bowel Syndrome
Yes
No
Blood Disorders
Yes
No
Crohn’s Disease
Yes
No
Thrombosis
Yes
No
Celiac Disease
Yes
No
Cancer
Yes
No
Ulcerative Colitis
Yes
No
Sexual Dysfunction
Yes
No
Gallbladder Disease
Yes
No
Recent Physical Symptoms
Other Health Conditions
Loss of Consciousness/Fainting
Yes
No
Tremors
Yes
No
Dizziness
Yes
No
Shuffling/Slow Gait
Yes
No
Loss of Balance
Yes
No
Low Energy
Yes
No
Headaches
Yes
No
Shortness of Breath
Yes
No
Change in smell
Yes
No
Change in taste
Yes
No
Incontinence
Yes
No
Bowel Issues
Yes
No
Blurred Vision
Yes
No
Mis-reaching for items (e.g. door handles)
Yes
No
Neuropathy/ Loss of Sensation/Tingling
Yes
No
Sleep Difficulties
Yes
No
Slurred Speech
Yes
No
Difficulties Swallowing:
Yes
No
SURGERY
Date
1.
Date
MM slash DD slash YYYY
2.
Date
MM slash DD slash YYYY
3.
Date
MM slash DD slash YYYY
HOSPITALIZATION REASON
Date
1.
Date
MM slash DD slash YYYY
2.
Date
MM slash DD slash YYYY
3.
Date
MM slash DD slash YYYY
Signature
Quick Inquiry
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