Health Information | LIFE TO THE NEEDY HOMECARE

Do you have any medical conditions or health concerns we should be aware of?*

Yes

No

Please Specify if yes*

Are you currently taking any medications?*

Yes

No

If yes, please list them:*

Do you have any allergies (food, medications, environmental, etc.)? *

Yes

No

If yes, please specify:*

Do you have any mobility issues or use any mobility aids (e.g., wheelchair, walker)?*

Yes

No

Have you recently been hospitalized or undergone any surgeries? *

Yes

No

If yes, please provide details:*