Please take about 3 to 5min to complete the form and start your caregiving journey with Red Crowns Caregivers. We will contact you within a working day upon receiving your submission.
Tell us about yourself.
Would you like to start your life-changing journey with Red Crowns Caregivers? First things first—kindly take 3 to 5 minutes of your time to accomplish this Health Care Assessment. Upon submitting it, we will get in touch with you within one business day or so.
Purpose of the form
By filling out this assessment form, you are informing us of your health and medical conditions. We need to be aware of your medical history and present conditions. This way, we will be able to formulate the best care plan for you. This is also to prevent any unwanted incidents from occurring (e.g. allergic reactions to food, missing out on important medications, etc.).
Kindly fill out the needed details of your employer (if you have one). Employers also play a vital role in the health care system of their workers. With that said, we want to align our values and services with them as well.
If you are being supported by a family member or anyone, please do input their details as well. This is for us to know and verify that there will be someone to shoulder your medical care expenses (especially if you are coming from a low-income household). As not all seniors can afford the costs of medical and nursing care, we understand and may help with the need to seek financial assistance.
Health & Medical Conditions – Physical Condition of Occupant
The most important part—we need to be informed of your physical and other medical-related conditions. As our services are meant for the improvement of your well-being, we need to know if you have any issues that we need to address or watch out for. Also, you can inform us if you have any special needs or requests related to your health.