Client Intake & Observational Questionnaire

This form helps Adele understand your mom’s situation fully so she can support her safely and appropriately.

Confidentiality: All information is kept strictly confidential and used only for professional support and care planning.

Personal Details

Your Name Your relationship to your mom Your mom’s full name Date of birth Age

Brief Essential History

Please share any significant life events that may be important (e.g. loss of a spouse, trauma, major illness, recent changes, emotional shocks) Please share her medical history (e.g. diagnoses, surgeries, chronic conditions, allergies, hospitalisations) Please list all current medication, supplements, or treatments (include dosage if known)

Recent Fall & Physical Experience

When did the fall happen? (approximate date is fine) What happened during the fall? Please describe the incident in as much detail as possible Was she injured at all, even slightly? What did doctors say? Since the fall, what physical symptoms has she experienced? (e.g. dizziness, weakness, pain, imbalance) When she tries to stand or walk, what exactly happens step-by-step? Has she been checked for blood pressure changes when standing or inner ear/balance issues? Do you know her Alprazolam dosage and when it was started?

Cognitive & Awareness

Is she fully aware of where she is, who people are, and what is happening around her? Have you noticed any confusion, forgetfulness, personality changes, or unusual behaviour? Can she hold a normal conversation like before?

Emotional & Behavioural

Before the fall, how independent was she in daily life? Since the fall, what does she say about walking? (e.g. “I can’t walk”, fear, refusal) Does she seem afraid of falling again? If so, how does this show? How does she respond when someone gently encourages her to stand or walk?

Mobility & Support

Can she stand at all with support? Has a physiotherapist, nurse, or doctor tried to assist her with walking? What was the outcome when support was given?

Environment & Care

Is she currently at home or in a care facility? Who is with her during the day? Is she receiving any rehabilitation or therapy support?

Final Reflection

Is there anything else you feel may be important or helpful for Adele to know?

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