LifeStyle Options, Inc.

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REFER YOURSELF OR FAMILY OR A PATIENT

Now in our third decade, LifeStyle Options Inc. is a leader in providing exceptional, high quality home care services. To make a referral, simply complete the brief referral form. One of our Care Managers will call you during the next business day. To make absolutely certain we have captured exactly what you or your family member needs, we encourage you to complete this Plan of Care form. Should you prefer an in-person visit, simply call our office to schedule a no-cost, no obligation care conference.
Referral made by

Primary Care Physician

Physician Phone

Your Name

Your Phone

Relationship to Client

Your Email

Client Information

Name

Marital Status

Address

City

State

Zip

Phone

Date of Birth

Referred By

Home Health Agency	Hospital
Friend	Case Manager
Internet	Trust Officer

Other

Type of Sevice Requested

Level of Care Requested

Environment

Smoking Household?

Pets

Goals

Promote Independence	Promote Hygiene
Ensure Safety	Assist with Ambulation
Assist With Nutrition	Encourage Socialization
Emphasize Orientation

Other

Mental Status

Problem with Memory	Problem with Moods
Problem with Sleep	Oriented
Forgetful	Withdrawn/Depressed

Notes

Medical History

Allergies

Physical Information

Height

Weight

Poor Vision	Poor Hearing
Limited Mobility

Notes

Ambulation

Walker	Cane
Personal Assist	Self
Stand By Assist	Wheelchair

Equipment

Oxygen	Hoyer Lift
Gait Belt	Bedside Commode
Hospital Bed	Shower Chair

Other

TPR	Catheter Care
PT	Blood Pressure

Notes

Personal Care

Bathing	Shower
Dressing	Wash Hair
Skin Care	Mouth/Teeth Care
Dressing Changes	Chronic Indwelling Catheter

Notes

Incontinent Care

Bowel

Depends

Other Care

Medication Reminders?	Meal Preparation?
Assist with Feeding?	Difficulty chewing/swallowing?

Special Diet

Housekeeping Duties

Emergency Contact #1

Name

Relationship to Client

Address

City

State

Zip

Home Phone

Work Phone

Mobile Phone

Emergency Contact #2

Name

Relationship to Client

Address

City

State

Zip

Home Phone

Work Phone

Mobile Phone

Billing Contact

Name

Relationship to Client

Address

City

State

Zip

Phone