Champlain - Preliminary Screener

This pre-screener is a new initiative for Home and Community Care Support Services Champlain. We are always looking to improve - if you have any feedback about this form, please call 310-2222.

This pre-screener is intended for information purposes only. If you are in need of urgent medical attention, please call 911 or go to your nearest emergency department.

We aim to be in touch regarding your request within 2 business days. If you feel you require immediate service, or if you experience any difficulties completing the form, please call us directly at 310-2222 to discuss your needs with an intake team member.

This pre-screener only applies to people 18 years and above. If you are younger than 18 years old, or completing on behalf of someone younger than 18 years old, please contact Home and Community Care Support Services Champlain directly at 310-2222.

Thank you for making this request. Please select if you are making this request for your self or someone else and enter your contact information below.

Please note that if you are making this request on behalf of someone else, you will need their Health Card Number and date of birth to complete and submit the form.

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I am making this request for *

#1: Making Daily Decisions

Thinking about everyday decisions, such as choosing when to get up, when or what to eat, what clothes to wear, or what activities to do *

#2: Activities of Daily Living

Think about the past 24 hours (if the person has not done these activities in the past 24 hours, think about the last time they did).

a) For bathing, does the person need help getting in and out of the tub or shower? *

b) For bathing, does the person need help washing their upper body? (Do not include washing their hair or back) *

c) For bathing, does the person need help washing their lower body? *

d) For personal hygiene, think about the person combing their hair, brushing their teeth, or washing and drying their face and hands. (Do not count baths and showers.) *

e) For getting dressed or undressed, think about how the person dresses and undresses from the waist down. Include belts, pants, skirts, shoes, prosthetics, orthotics, etc. *

f) How does the person get around? Think about when they are walking, using a wheelchair, a walker or other mobility devices between areas on the same floor. *

#3: Shortness of Breath

When does the person feel out of breath? *

#4: Health

Ask the person this question: “How would you rate your health?” Enter their answer or select I don’t know if you are unable to obtain the answer. *

The person has health issues/conditions which impact their thinking, daily activities, mood, or behaviour. These issues are getting worse, or they change often. *

Right now, the person is having a flare-up of a recurring or long-term health issue, or they have a new, recent illness or injury that affects their day-to-day activities. *

#5: Mood

Ask the person this question: “In the last 3 days have you felt sad, depressed or hopeless?” Enter their answer or select I don’t know if you are unable to obtain the answer. *

#6: Caregivers

An informal caregiver is an unpaid person (for example, a family member, close friend, neighbour, or other person) who helps the person with their daily activities.

If you are the informal caregiver or know the informal caregiver who provides most of the person’s care, are you or are they feeling distress, anger, depression or feel that you or they are struggling to cope? *

Are family or close friends saying they are feeling overwhelmed by the person’s illness? *

#7:

Is the person taking 3 or more prescribed medications per day? *

#1: Making Daily Decisions

Thinking about everyday decisions, such as choosing when to get up, when or what to eat, what clothes to wear, or what activities to do *

#2: Activities of Daily Living

Think about the past 24 hours (if you have not done these activities in the past 24 hours, think about the last time you did).

a) For bathing, do you need help getting in and out of the tub or shower? *

b) For bathing, do you need help washing your upper body? (Do not include washing your hair or back) *

c) For bathing, do you need help washing your lower body? *

d) For personal hygiene, think about combing your hair, shaving, brushing your teeth, or washing and drying your face and hands. (Do not count baths and showers.) *

e) For getting dressed or undressed, think about how you dress and undress from the waist down. Include belts, pants, skirts, shoes, prosthetics, orthotics, etc. *

f) How do you get around? Think about walking, using a wheelchair, a walker or other mobility devices between areas on the same floor. *

#3: Shortness of Breath

When do you feel out of breath? *

#4: Health

In general, how would you rate your health? *

I have health issues/conditions which impact my thinking, daily activities, mood, or behavior. These issues are getting worse, or they change often. *

Right now, I am having a flare-up of a recurring or long-term health issue, or I have a new, recent illness or injury that affects my day-to-day activities. *

#5: Mood

In the last three days, have you felt sad, depressed, or hopeless? *

#6: Caregivers

An informal caregiver is an unpaid person (for example, a family member, close friend, neighbour, or other person) who helps the person with their daily activities.

Has the informal caregiver who provides most of your care shared feelings of distress, anger, depression, or told you that they are struggling to cope? *

Are family or close friends saying that they are feeling overwhelmed by your illness? *

#7

Are you taking 3 or more prescribed medications per day? *

Please use this box to provide any additional information you would like us to know; in particular, what sort of help you are looking for:

Please leave this field empty

I have reviewed the privacy consent policy (click here to review). *

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This pre-screener is a new initiative for Home and Community Care Support Services Champlain. We are always looking to improve - if you have any feedback about this form, please call 310-2222.

Referrer Information

Referrer Name *

Relationship to person / Name of referring organization *

Telephone Number *

Email address *

Is the person aware this request is being made? *

Person’s Information

First name *

Last name *

Telephone Number *

Address: *

Email address *

Birthdate *

Sex *

Health Card Number *

Version Code *

Primary Language *

Please specify other language in the primary language text box and select from drop-down below if an interpreter is required. *

To help us understand the person’s care needs, please select the answers that best describe the persons’ situation.

First name *

Last name *

Telephone Number *

Address: *

Email address *

Birthdate *

Sex *

Health Card Number *

Version Code *

Primary Language *

Please specify other language in the primary language text box and select from drop-down below if an interpreter is required. *

To help us understand your care needs better, please select the answers that best describe your situation.

#1: Making Daily Decisions

Thinking about everyday decisions, such as choosing when to get up, when or what to eat, what clothes to wear, or what activities to do *

#2: Activities of Daily Living

Think about the past 24 hours (if the person has not done these activities in the past 24 hours, think about the last time they did).

a) For bathing, does the person need help getting in and out of the tub or shower? *

b) For bathing, does the person need help washing their upper body? (Do not include washing their hair or back) *

c) For bathing, does the person need help washing their lower body? *

d) For personal hygiene, think about the person combing their hair, brushing their teeth, or washing and drying their face and hands. (Do not count baths and showers.) *

e) For getting dressed or undressed, think about how the person dresses and undresses from the waist down. Include belts, pants, skirts, shoes, prosthetics, orthotics, etc. *

f) How does the person get around? Think about when they are walking, using a wheelchair, a walker or other mobility devices between areas on the same floor. *

#3: Shortness of Breath

When does the person feel out of breath? *

#4: Health

Ask the person this question: “How would you rate your health?” Enter their answer or select I don’t know if you are unable to obtain the answer. *

The person has health issues/conditions which impact their thinking, daily activities, mood, or behaviour. These issues are getting worse, or they change often. *

Right now, the person is having a flare-up of a recurring or long-term health issue, or they have a new, recent illness or injury that affects their day-to-day activities. *

#5: Mood

Ask the person this question: “In the last 3 days have you felt sad, depressed or hopeless?” Enter their answer or select I don’t know if you are unable to obtain the answer. *

#6: Caregivers

An informal caregiver is an unpaid person (for example, a family member, close friend, neighbour, or other person) who helps the person with their daily activities.

If you are the informal caregiver or know the informal caregiver who provides most of the person’s care, are you or are they feeling distress, anger, depression or feel that you or they are struggling to cope? *

Are family or close friends saying they are feeling overwhelmed by the person’s illness? *

#7:

Has the person had 2 or more falls in the last year? *

Is the person taking 3 or more prescribed medications per day? *

#1: Making Daily Decisions

Thinking about everyday decisions, such as choosing when to get up, when or what to eat, what clothes to wear, or what activities to do *

#2: Activities of Daily Living

Think about the past 24 hours (if you have not done these activities in the past 24 hours, think about the last time you did).

a) For bathing, do you need help getting in and out of the tub or shower? *

b) For bathing, do you need help washing your upper body? (Do not include washing your hair or back) *

c) For bathing, do you need help washing your lower body? *

d) For personal hygiene, think about combing your hair, shaving, brushing your teeth, or washing and drying your face and hands. (Do not count baths and showers.) *

e) For getting dressed or undressed, think about how you dress and undress from the waist down. Include belts, pants, skirts, shoes, prosthetics, orthotics, etc. *

f) How do you get around? Think about walking, using a wheelchair, a walker or other mobility devices between areas on the same floor. *

#3: Shortness of Breath

When do you feel out of breath? *

#4: Health

In general, how would you rate your health? *

I have health issues/conditions which impact my thinking, daily activities, mood, or behavior. These issues are getting worse, or they change often. *

Right now, I am having a flare-up of a recurring or long-term health issue, or I have a new, recent illness or injury that affects my day-to-day activities. *

#5: Mood

In the last three days, have you felt sad, depressed, or hopeless? *

#6: Caregivers

An informal caregiver is an unpaid person (for example, a family member, close friend, neighbour, or other person) who helps the person with their daily activities.

Has the informal caregiver who provides most of your care shared feelings of distress, anger, depression, or told you that they are struggling to cope? *

Are family or close friends saying that they are feeling overwhelmed by your illness? *

#7

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