Home Health Intake Form

The Home Health Intake Form is specifically designed for home health agencies, capturing the comprehensive admission assessment data that home health clinicians need to develop individualized care plans for homebound patients. This template collects patient demographics alongside a thorough assessment of homebound status justification, functional limitations (ADLs and IADLs), mobility and ambulation (assistive device use, stairs, fall history), cognitive status, communication abilities, nutritional assessment (weight, diet, swallowing ability, feeding assistance needs), skin integrity assessment, pain management status, bowel and bladder function, and vital sign baseline.

Built for Medicare-certified home health agencies, visiting nurse associations, home-based primary care, and transitional care programs, this form includes sections for hospital discharge information (discharge date, diagnosis, procedures performed, discharge medications), skilled service needs assessment (skilled nursing, physical therapy, occupational therapy, speech therapy, medical social work, home health aide), current physician orders and treatment plans, emergency plan (hospital preference, DNR status, emergency contacts), medication management assessment (ability to self-manage, medication reconciliation, pharmacy information, high-risk medications), caregiver availability and capability, home environment assessment (safety hazards, accessibility, medical equipment in home), and insurance verification including Medicare eligibility and episode dates.

All fields are HIPAA-compliant and aligned with OASIS data collection requirements for Medicare-certified home health agencies. The structured format supports regulatory compliance while ensuring comprehensive patient assessment. The home safety section identifies environmental hazards that may increase fall risk or impede care delivery, enabling proactive intervention. Pre-admission completion by referral sources or intake coordinators streamlines the admission process and ensures that the first home visit is productive and focused on direct patient care.