Service Application I. CLIENT INFORMATION -- Province --OntarioSaskatchewanPrince Edward IslandNunavutNova ScotiaNorthwest TerritoriesNewfoundland & LabradorNew BrunswickManitobaBritish ColumbiaAlbertaQuebecYukon What language(s) you speak? EnglishFrenchRussianHebrewUkrainianRomanian Gender MaleFemale II. MEDICAL CONDITION Mental Issues Mobility Issues Cancer Hearing OKLimited Speech OKLimited Vision OKLimited Mobility OKLimited Swallowing OKLimited Breathing OKLimited Cognitions OKLimited III. FAMILY DOCTOR INFORMATION (OPTIONAL) -- Province --OntarioSaskatchewanPrince Edward IslandNunavutNova ScotiaNorthwest TerritoriesNewfoundland & LabradorNew BrunswickManitobaBritish ColumbiaAlbertaQuebecYukon IV. SERVICES REQUESTED MondayTuesdayWednesdayThursdayFridaySaturdaySunday Housemaking/Housekeeping Vacuum/Sweep FloorsWet Mop FloorsDust FurnitureClean Kitchen SurfacesClean Refrigerator (Inside)Clean Stove and OvenClean MicrowaveChange Bed LinenMake BedPrepare BreakfastPrepare LunchPrepare DinnerClean Bathroom SinkClean Bathtub/ShowerClean ToiletLaundry (Washer/Dryer) Companion/Sitter CompanionshipTransportation & EscortClean Stove and OvenClean MicrowaveMeal Preparation, Serving & Clean-upMedical RemindingShopping Personal Care Assisting with Bath/ShowerBed BathStand by for safetyShaving (face,legs,underarms)Brush teethNail care (filing)Routine skin careDressing/undressingWash hands/faceToileting - toilet,commode,bedpanAssist with eating/drinking, utensils, adaptive devicesToilet hygieneChanging diapers (i.e. Depends)Supervision/encouragementTransferringPositioningAssist with walking/wheel chair, cane
