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Name
Location
*I understand that Safe at Home currently only serves clients in Southern Nevada.
Age
18-35
36-49
50-63
64+
HT
Weight
Mobility device
Ambulatory
Cane
Walker
Wheelchair
Bed Bound
Does anyone live with the client?
Yes
No
Household members
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
How many days per week?
1
2
3
4
5
6
7
Hours per day
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Activity:
Bathing
Dressing
Grooming
Alzheimer's/Dementia
Toileting
Transferring
Mobility/Ambulation
Eating
Light Housekeeping
Laundry
Shopping
Meal Preparation
Medical History
i) Hypertension
ii) Diabetes
iii) Alzheimer's
iv) Dialysis
Insurance
Medicaid
Medicare
Private Insurance
Private Pay
Yes
No
Languages spoken
English
Spanish
French
Email
Phone Number
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