Intake Assessment Form

Please complete the encrypted and secure form below and a member of our staff will be in touch.

Please read our HIPAA Forms Privacy Statement here. You’ll be asked to agree to it before you submit the form below.

Company

Personal Information

First Name *

Last Name *

Age *

Date of Birth *

Sex *

Male

Female

Other

Marital Status *

Single

Married

Widowed

Divorced

Separated

Social Security Number

Address *

Email *

What phone number is best for you? *

Home Cell

How did you hear about PACE at Element Care?

Have you moved in the past 2 years? *

Yes No

Is your housing temporary? *

Yes No

Do you live alone? *

Yes No

Do you speak English? *

Yes No

Race

Ethnicity

Religious Preference

Do you have a cell phone? *

Yes No

Do you have computer access? *

Yes No

Highest Level of Education?

Former Occupation?

Number of Children?

Do you drive? *

Yes No

Who should Element Care contact about your healthcare?

Emergency Contact #1

First Name *

Last Name *

Relationship *

Address *

Phone Number *

Email *

Do you have a healthcare proxy filled out? *

Yes No Unsure

Emergency Contact #2 (Optional)

First Name

Last Name

Relationship

Address

Phone Number

Do you smoke? *

Yes No

Are you on oxygen? *

Yes No

Do you drink alcohol? *

Yes No

Do you use drugs? *

Yes No

Any pain? Please list where on your body.

Do you use any Assistive Devices to get around? *

Cane

Walker

Rollator

Wheelchair

Power Wheel Chair

I don't use Assistive Devices

Any falls in the last 6 months? *

Yes No

Your Primary Care Physician (PCP)

Please list any information you know below.

First and Last Name

Address/Town/Phone

Specialists

Example: "Cardiologist"

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Last Hospitalization

If they admitted you, what hospital and what month/year about?

What was the reason?

Number of hospitalizations in the last 12 months?

Past Medical History/Medical Problems

Example: Diabetes, CHF, Depression

Past Surgical History

Example: Replacements, Cardiac Surgery, etc...

Current Medications

List name, dose of medication, and how often you take.

Any allergies to medications or anything else?

List names

What pharmacy do you use?

Pharmacy Phone Number

Formal Home Supports

Services (check all that apply)

Homemaker

Companion

Lifeline

Help Bathing

Home Delivered Meals

Medication Reminders

Help with Paying Bills

Someone to Help Cook

Dressing

Eating

Do you have a visiting nurse see you? *

Yes No

Do you use any of the following services?

North Shore Elder Services

Senior Care

Minuteman

Mystic Valley

Elder Services of Merrimack Valley

No, I don't use any of them.

Do you have a Case Manager? *

Yes No

Do you know what agency your aid is from? *

Yes No

Any issues in home/apartment? Safety Issues? Weapons?

Skin issues? Please list any.

Monthly Income

Monthly Income Estimate

Income Sources (check all that apply) *

Social Security

SSI

SSDI

Pension

Assets

Bank Accounts

Checking Savings

Life Insurance *

Yes No

Retirement funds? Please list.

Pre-Paid Burials? *

Yes No

Health Insurance Information

Who do you have for Insurance? *

Policy Number

INTAKE ASSESSMENT FORM

Please complete the encrypted and secure form below and a member of our staff will be in touch.

Please read our HIPAA Forms Privacy Statement here. You’ll be asked to agree to it before you submit the form below.

Phone

Personal Information

First Name *

Last Name *

Age *

Date of Birth *

Sex *

Male

Female

Other

Marital Status *

Single

Married

Widowed

Divorced

Separated

Social Security Number

Address *

Email *

What phone number is best for you? *

Home Cell

How did you hear about PACE at Element Care?

Have you moved in the past 2 years? *

Yes No

Is your housing temporary? *

Yes No

Do you live alone? *

Yes No

Do you speak English? *

Yes No

Race

Ethnicity

Religious Preference

Do you have a cell phone? *

Yes No

Do you have computer access? *

Yes No

Highest Level of Education?

Former Occupation?

Number of Children?

Do you drive? *

Yes No

Who should Element Care contact about your healthcare?

Emergency Contact #1

First Name *

Last Name *

Relationship *

Address *

Phone Number *

Email *

Do you have a healthcare proxy filled out? *

Yes No Unsure

Emergency Contact #2 (Optional)

First Name

Last Name

Relationship

Address

Phone Number

Do you smoke? *

Yes No

Are you on oxygen? *

Yes No

Do you drink alcohol? *

Yes No

Do you use drugs? *

Yes No

Any pain? Please list where on your body.

Do you use any Assistive Devices to get around? *

Cane

Walker

Rollator

Wheelchair

Power Wheel Chair

I don't use Assistive Devices

Any falls in the last 6 months? *

Yes No

Your Primary Care Physician (PCP)

Please list any information you know below.

First and Last Name

Address/Town/Phone

Specialists

Example: "Cardiologist"

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Name

Address/Town/Phone

Last Hospitalization

If they admitted you, what hospital and what month/year about?

What was the reason?

Number of hospitalizations in the last 12 months?

Past Medical History/Medical Problems

Example: Diabetes, CHF, Depression

Past Surgical History

Example: Replacements, Cardiac Surgery, etc...

Current Medications

List name, dose of medication, and how often you take.

Any allergies to medications or anything else?

List names

What pharmacy do you use?

Pharmacy Phone Number

Formal Home Supports

Services (check all that apply)

Homemaker

Companion

Lifeline

Help Bathing

Home Delivered Meals

Medication Reminders

Help with Paying Bills

Someone to Help Cook

Dressing

Eating

Do you have a visiting nurse see you? *

Yes No

Do you use any of the following services?

North Shore Elder Services

Senior Care

Minuteman

Mystic Valley

Elder Services of Merrimack Valley

No, I don't use any of them.

Do you have a Case Manager? *

Yes No

Do you know what agency your aid is from? *

Yes No

Any issues in home/apartment? Safety Issues? Weapons?

Skin issues? Please list any.

Monthly Income

Monthly Income Estimate

Income Sources (check all that apply) *

Social Security

SSI

SSDI

Pension

Assets

Bank Accounts

Checking Savings

Life Insurance *

Yes No

Retirement funds? Please list.

Pre-Paid Burials? *

Yes No

Health Insurance Information

Who do you have for Insurance? *

Policy Number

Element Care PACE
235 Woodland North
Lynn MA 01904

Upon enrollment participants must receive all health care, primary care and specialist physician services–other than emergency services–as authorized by PACE, or be fully and personally liable for costs of unauthorized services.

View our privacy policy , non-discrimination notice & accessibility options

H2222_2017_WC_1
Last updated Aug 19 2019

INTAKE ASSESSMENT FORM

Please complete the encrypted and secure form below and a member of our staff will be in touch.

Personal Information

Emergency Contact #1

Emergency Contact #2 (Optional)

Your Primary Care Physician (PCP)

Specialists

Last Hospitalization

Past Medical History/Medical Problems

Past Surgical History

Current Medications

Any allergies to medications or anything else?

Formal Home Supports

Monthly Income

Assets

Health Insurance Information

INTAKE ASSESSMENT FORM

Please complete the encrypted and secure form below and a member of our staff will be in touch.

Personal Information

Emergency Contact #1

Emergency Contact #2 (Optional)

Your Primary Care Physician (PCP)

Specialists

Last Hospitalization

Past Medical History/Medical Problems

Past Surgical History

Current Medications

Any allergies to medications or anything else?

Formal Home Supports

Monthly Income

Assets

Health Insurance Information

Element Care PACE 235 Woodland North Lynn MA 01904

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Element Care PACE
235 Woodland North
Lynn MA 01904