- VOA Chesapeake & Carolinas

DOB:(Required)

Phone Number:(Required)

Referring Agency:(Required)

Reason for Medical Respite Referral:(Required)

Primary Medical Diagnosis(Required)

If the answer is yes to any of the above, the client will not meet medical criteria for admission to Hope Has A Home.

Does the client have dementia or cognitive impairment? If yes, please please describe more in detail what the limitations are.

Does the client have fecal or urinary incontinence? If yes, is the client able to manage on their own?

If the answer is yes, is the client able to safely manage their own oxygen supply including correct use of concentrator, ability to change valves on portable tanks, & basic triage of oxygen devices if there is malfunction?

Is the client going to be discharged with orders for controlled substances? If so, please specify.

HHAH Pre-Screening Questions