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Online Screening Tool

First Name

Last Name

County ChesterDecaturHardemanHardinHaywoodHendersonMadisonMcNairy

Address

I am seeking information or care for SelfParentSpouseRelativeFriendOther

Date of birth for person needing services

Consumer’s First Name

Consumer’s Last Name

Consumer’s Marital Status: SingleMarriedDivorcedWidowed

Consumer's Living Situation Lives aloneLives with spouseLives with spouse & othersLives with other relativesLives with a friendLives with a non-relative/paid helperother

Consumer's Phone Number

Emergency Contact Name

Emergency Contact Number

Assistance with the following tasks is needed: (Check all that apply) EatingDressing/GroomingToiletingBathingMobilityGetting In/Out of bed or chair

Assistance with the following household chores is needed (Check all that apply) Meal PreparationShoppingTelephone CallsMoney ManagementManaging MedicationTransportationHousekeeping

Does the consumer use a wheelchair? YesNoOther

Can the consumer do laundry? YesNo

Can consumer express his/or her basic needs or wants? YesNo

Can consumer follow simple instructions? YesNo

Is consumer oriented to person and place? YesNo

Does the consumer exhibit any aggressive behavior? YesNo

Most pressing needs are (Check all that apply) Personal CarePersonal Care AssistantHousekeepingHome Delivered MealsPersonal Emergency Response SystemInstitutional Respite (temporary relief for a caregiver)In-Home Respite (temporary relief for a caregiver)Care managementMinor Home Modification (i.e. wheelchair ramps, hand rails, etc.)Assisted Care LivingAdult Day CarePest ControlAssistive Technology Devices

Monthly income is for IndividualCouple

Monthly income level is No more than $849$850 - $1,140$1,141 - $1,430$1,431 - $1, 720$1,721 - $2,010$2,011 - $2,300$2,301 – $2,590$2,591 - $2,880More than $2,880Not Sure

Type of Insurance Medicare AMedicare A & BMedicare DMedicaidQMBLong Term CareMedicaid PendingVA

Is the consumer a veteran? YesNo

Does the consumer receive VA benefits? YesNo

Does the consumer receive the following public assistance? Food StampsSection 8 rentalSocial SecuritySSIOther

Is the consumer currently receiving any other services? YesNo

Medical conditions include (check all that apply) Ankle/Leg SwellingUrinary or Bowel problemsChronic PainAlzheimers or DementiaDepression or AnxietyMissing Limbs/amputationBreathing problemsTBCancerDiabetesHeart ProblemsStrokeCognitive DisabilityEpilepsy/TremorsArthritisHearing impairmentVision impairmentNoneOther

Primary Physician’s Name

Are there any pets in the home? YesNo

**The following questions are optional, and for statistical purposes only**

Ethnicity HispanicNot HispanicUnknown

Race American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther

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