Welcome to KenektCare!

Please fill out our client onboarding form. Please fill what applies and skip what does not. Thank you.

Full Name

Phone Number

Date of birth

Address

City

Postal code

Client Lives Alone?

Yes

No

Care Days Needed

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Care Hours

Medical Assessment

Primary diagnoses

Secondary Diagnoses

Medication

Medication Doses

Medication Frequency

1-2 times a day

3-4 times a day

5+ times a day

Morning

Noon

Night

Relevant Medical/ Surgical Information

Date

Condition

Details of Treatment

Allergies

Skin Condition

Intact

Redness

Decubitus ulcer

Excoriation

Diabetic

Type 1

Type 2

Insulin

Oral hypoglycemic

Diet Controlled

Behaviour

Compliant to care
Anxious
Restless
Agitated
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Aggression

Verbal

Physical

Sexual

Abuse

History of being abused

History of being abusive

Risks

Elopement

Falls

Agression

Choking

Social/ Family/ Issues/ Concerns

Functional Status

Transferring

Self

Assist

Total Care

Appetite

Good

Fair

Poor

Meal Prep

Self

Assist

Total care

Housework

Self

Assist

Total Care

Toiletting

Self

Assist

Incontinent

Bladder

Bowel

Feeding

Self

Assist

Total Care

Bathing

Self

Assist

Bad

Sensory Perception

Vision

Normal

Impaired

Blind

Contacts

Glasses

Hearing

Normal

Impaired

Deaf

Hearing Aid

Speech

Normal

Impaired

Aphasic

Other language spoken besides English

Literacy

Literate

Illiterate

Pain

None

Acute

Chronic

Activity

Mobility

Independent

Bedridden

Assistance Required

Assistive Devices

Mechanical Lifts

Walker

Cane

Crutches

Wheelchair

Other

Limbs

Normal

Impairment

Tremor

Amputation

Nutrition

Mouth

Own Teeth

Partial

Dentures

No Teeth

Ulcers

Infection

Drooling

Feeding Level

Independent

Supervision

Assistance

Total Feed

Choking Problem

Swallowing Problems

Diet

Supplements

Elimination

Bladder

Continent

Incontinent

Nocturia

Indwelling Catheter

In & Out Catheterization

Ileoconduit

Bowels

Continent

Incontinent

Self Care

Ostomy Care

Assist

Constipation

Total Care

Diarrhea

C. Difficile

0%