Home Health Questionnaire Form

* Required Information

Using complete sentences, please answer the following questions about the following scenarios

Name *

1. You have been providing homemaker services for Abigail for 6 months. Today she asks you to drive her to get ice cream. This is the first time she has made such a request as your regular tasks include cleaning her bathroom, kitchen and completing her laundry. Describe how you would respond to her request?

2. As a healthcare worker, you and Martin take the bus every Friday to volunteer at the food shelf. Today this bus is running late, and 20 minutes have passed. Martin is beginning to become very upset with you. He begins yelling at you and pacing rapidly on the street corner. How do you react to this situation?

3. John is a 20-yr. old man with autism. John does not communicate verbally or through sign language. John lives with his parents, who are his legal guardians. Today is your first day working with John. You were informed by the agency that John needs significant help in most areas of personal cares, such as grooming, hygiene, bathing, toileting dressing and eating. When you arrive for your shift, John’s parents communicate their expectations of you, including that they do not want John to sit and watch TV all day as he has done in the past. List 3 activities you could do with John during your shift and 3 tasks you must complete before the end of your shift.

4. Your regular shift begins at 8am to help Mary get ready for school and assist her with getting on the school bus. Today, on your way to work, you get a flat tire and know that you will be late to Mary’s home. Mary is a minor child who parents work. Who is the first person you should call to inform of your situation? Who do you call next?

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