Aloha Habilitation Sevices | Honolulu Hawaii

(808) 622-4200

info@alohahab.com

100 Kahelu Avenue Suite 110, Mililani, HI, 96789

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Home Health Care Assessment

If you are considering home care options for yourself or a loved one, please complete the following assessment to identify the type and level of care needed. All plans of care are tailored to your specific needs. Our registered nurse will contact you once you have submitted your assessment. Thank you for considering Aloha Habilitation Services with your healthcare needs!

Name*
First Last
Email*
Phone*
We need care for:*
- Myself
- A Family Member
- A Friend
- A Patient
The individual who needs help is:
- Aging
- Blind
- Disabled
- Chronically Ill
- Recovering from Cancer
- Recovering from Stroke
- Recovering from Surgery
- Recovering from Post-Hospitalization
- Diabetic
- Suffering Dementia/Alzheimer’s
- Has an Intellectual/Developmental Disability
The frequency of services need is:
- Morning
- Afternoon
- Evening
- Overnight
- 24 hours
- 1-2 days/week
- 3-4 days/week
- 5-7 days/week
The individual needs assistance with the following:
- Activities of Daily Living
- Transfers
- Meal Preparation
- Housekeeping
- Incontinence
- Transportation
- Running Errands
- Companionship
- Therapy and Skilled Nursing
- Administration of Medications/Injections
- Monitoring of Health Status
- Wound Care
- Pain Management
Name
This field is for validation purposes and should be left unchanged.