Submitted on: 07/08/2019 11:21:40 AM
Completion time: 20 min. 59 sec.

Client Name and Address
	Doris Pierce
	806-385-9922
	dorothy.wilson@interimhh.com
	East 14th street
	TX
	Littlefield
	79339
	Hockley

Client's Age at Referral: 81
DOB: 07-29-1937
Client's Gender: Female
Client's Ethnicity: Caucasian

Is this a hospice patient? Yes
Is this a dialysis patient? No
Is this a handicapped person living alone? Yes
Did this person serve in the military? No

Is there a financial need, based on your agency's guidelines? Yes
Does the Client Own or Rent their home? Rent

Caretaker /Other Contact  Name
	Pam Pickard
	806-729-4136

Ramp Information
Where is the ramp needed? (Be specific: front of house, side door, etc...) 
front entry of home

Provide a brief description of the obstacle(s) 
(e.g. a door threshold, a single step, a mobile home with three steps, etc...)
two steps to get to the front entry of home with a combined height of aprox 13 inches

Provide details of the client's mobility that are relevant to a ramp 
(e.g. walking, assisted walking, manual wheelchair, powered wheelchair, etc.). 
Also include a prognosis if this is expected to change.

person is able to ambulate with a walker in home at this time. 
patient uses a wheelchair when she leaves home with daughter. 
Patient experiences shortness of breath and weakness. 
Person is cognitively intact and has support from her daughter and son.

Is there an existing dangerous ramp at the client's home? Yes

Referring Social Worker Full Name: D. Leigh Wilson
Name of Referring Agency: Interim Home Health (hospice)
Referring Social Worker's Phone: 806-782-2078
Referring Social Worker's Email: dorothy.wilson@interimhh.com