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Home Health Assessment Form Template

Streamline patient evaluations with our home health assessment form

Finding the right way to assess your patients at home can be challenging, but our Home Health Assessment Form Template is designed to ease that process. This template is perfect for healthcare practitioners who need to evaluate patient needs efficiently and effectively. Benefit from clearer patient histories, improved care coordination, and simplified data collection, all while ensuring compliance with healthcare standards like WCAG-aligned labels. Experience how our live template can enhance your assessments today.

Use this Template (FREE) Live Preview
Full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Phone number
Email address
Home address
Preferred contact method
Phone call
Text message
Email
Any
Primary language
English
Spanish
Other
Please Specify:
Interpreter needed
Yes
No
Emergency contact full name
Emergency contact phone
Relationship to patient
Spouse/Partner
Parent
Child
Sibling
Relative
Friend
Neighbor
Caregiver
Other
Please Specify:
Primary caregiver at home
None
Family caregiver
Hired caregiver
Visits as needed
Do you live alone
Yes
No
Primary health concerns today
Is this assessment for starting home health services
Yes
No
Referral source
Self
Family
Physician
Hospital or clinic
Insurance
Other
Please Specify:
Preferred visit times
Morning
Afternoon
Evening
Weekend
No preference
Current or past conditions (select all that apply)
Please Specify:
Past surgeries or hospitalizations
Primary care provider name
Date of last hospital discharge (if applicable)
Tobacco use
Never
Former
Current daily
Current occasional
Prefer not to say
Alcohol use
Never
Occasionally
Weekly
Daily
Prefer not to say
Recreational drug use
Yes
No
Prefer not to say
Current medications (name, dose, frequency)
Any medication allergies
Yes
No
If yes, list medication allergies
Other allergies (food, latex, environmental)
Do you manage your medications independently
Yes
Sometimes
No
Do you need help with any of the following
Mobility aids used
None
Cane
Walker
Wheelchair
Scooter
Other
Please Specify:
Falls in the past 12 months
No falls
1 fall without injury
1 fall with injury
2 or more falls without injury
2 or more falls with injury
Prefer not to say
Pain level today (0-5)
0 Not at all likely
1
2
3
4
5 Extremely likely
Type of residence
Single-family home
Apartment or condo
Assisted living
Other
Please Specify:
Home safety features present
Home hazards or concerns
Any pets in the home
No
Dog
Cat
Prefer not to say
Other
Please Specify:
Other symptom details
Height (include units)
Weight (include units)
Blood pressure (if known)
Blood sugar/glucose today (if applicable)
Oxygen saturation SpO2 (if known)
Current symptoms (select all that apply)
Goals for home health services
Preferred clinician types
Registered Nurse
Physical Therapist
Occupational Therapist
Speech Therapist
Medical Social Worker
Home Health Aide
Not sure
Cultural, dietary, or religious considerations
Permission to contact your healthcare providers to coordinate care
Yes
No
Insurance provider
Member ID
Group number (if applicable)
Policy holder name
I agree to receive a home health assessment and understand this is not a medical emergency service
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I acknowledge that the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Printed name of person completing this form
Date signed
Relationship to patient
Self
Parent/Guardian
Medical power of attorney
Spouse/Partner
Family member
Caregiver
Other
Please Specify:
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Paper art illustration depicting a home health assessment form for an article on FormCreatorAI.

When to use this form

Use this assessment when you onboard a new client, after a hospital discharge, or when a condition or living situation changes. It helps you capture health status, daily-living abilities, medications, safety risks, and support needs so you can build a clear care plan and schedule the right visits. Care coordinators, nurses, and family caregivers benefit from a shared snapshot that guides tasks and prevents gaps. Pair it with the Caregiver daily log form to track day-to-day changes, and the Home care timesheet form to record hours and verify visits. If a client needs a higher level of care, your findings can also inform a Nursing home application form discussion.

Must Ask Home Health Assessment Questions

  1. Which activities of daily living do you need help with (bathing, dressing, toileting, eating, mobility)?

    This defines the level of assistance, visit length, and equipment you must set up. Clear ADL needs let you assign the right caregiver skills and avoid missed tasks.

  2. What medications do you take, with doses, schedule, and who organizes them?

    This prevents errors and flags risks like interactions or missed doses. You can coordinate refills and train caregivers on safe administration.

  3. Have you had any recent falls or home safety risks (stairs, lighting, rugs, pets), and what equipment is in place?

    Fall history and hazards drive home modifications and urgency of supervision. The answer tells you if you should add grab bars, lighting, or a therapy referral.

  4. Who is your primary caregiver, how often are they available, and what visit times work best?

    This sets a realistic schedule and avoids burnout or coverage gaps. It also clarifies backup contacts and preferred communication.

  5. What are your care goals and any advance directives or hospice status?

    Goals of care shape interventions, from rehab focus to comfort measures. If symptom management is the priority, align the plan with the Hospice nursing assessment form.

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