AdvantagePlusCaregivers.com®
We're all about the Care!
A Group of Independently Owned and Operated Franchises
Corporate Website
Canoga Park
Camarillo
6800 Owensmouth Ave., Suite 420
Canoga Park, CA 91303
800-687-8066
Phone:
805-322-8822
Email:
Contact Us
License No.: 194700149
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Title
First Name
Middle Name
Last Name
Address 1
Address 2
City
State
-- Please select --
Alabama
Alaska
American Samoa
Arizona
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Armed Forces Americas
Armed Forces Europe, Middle East, & Canada
Armed Forces Pacific
California
Colorado
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Delaware
District of Columbia
Federated States of Micronesia
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Northern Mariana Islands
Ohio
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Palau
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Gender
Male
Female
Email
Main Phone
Mobile/ Cell
Home Phone
Date of Birth (Optional)
Height
Weight
Billing Address
Address 1
Address 2
City
State
-- Please select --
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Europe, Middle East, & Canada
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Principal Diagnosis
Prognosis
-- Please select --
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Europe, Middle East, & Canada
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Nutritional Requiremens
DME and Supplies
Allergies
Safety Measures
Special Measures
Comments or Concerns
Nutritional and Feeding Instructions
Normal
Diabetic
Low Sodium
Liquid Only
Assist with Meal Preparations
Assistance with Feeding
Feeding Instructions
Functional Limitations
Amputation
Incontinence
Contracture
Hearing
Paralysis
Endurance
Ambulation
Speech
Legally Blind
Dyspnea
Other
Activites Permitted
Complete Bedrest
Bedrest BRP
Partial Weight Bearing
Up as Tolerated
Prescribed Exercises
Uses Crutches
Independent At Home
Uses Wheelchair
Uses Walker
Transfers Bed/Chair
No Restrictions
Uses Cane
Other (Specify)
Mental Status
Oriented
Comatose
Forgetful
Agitated
Disoriented
Lethargic
Depressed
Other (Specify)
Mobility
Assist with Ambulation
Assist with Transfers
Assist with ROM Exercises
Assist Transfers Bed/Chair only
Other (Specify)
Toileting
Bathroom
Bedpan
Diapers
Urinal
Commode
Bathing
Partial Bathing
Complete
Tub
Shower
Sponge Bath
Sink
Other (Specify)
Vision Loss
Right Eye
Left Eye
Clean Glasses
Peripheral Only
Wears Glasses
Hearing
Hard of Hearing
Deaf
Wears Hearing Aid
Skin Care
Moisturizer
Powder
Other Skincare
Hair Care
Wash and Dry
Comb and Brush Only
Wash and Set
Oral Care
Brush and Floss
Denture Care
Shaving
Shave Face
Shave Axilla
Safety Razor
Shave Legs
Electric Razor
Nail Care
Clean
Polish
File and Trim
Dressing
Self Dresses
Assist with Dressing
Help Select Clothes
Driving
Drives Self
Caregiver May Take Out
Call Before Taking Out
Waiver Of Liablity On File
Accompany on Taxi/Bus
Client's Car
Caregiver's Car
Recreation
Outdoor Recreation
Guidelines
Instrumental Activities of daily living
Housekeeping
Outdoor Recreation
Guidelines
Laundry
Can they collect dirty clothes for washing
Can they sort clothes properly
Can access laundry facilities
Can they load and unload clothes
Can they handle soap, bleach, etc..
Can they move to washer to dryer and hang
Can They put away clothes ok
Cooking
Can they prepare own meals
Can they plan well-balanced meals
Can they safely operate kitchen utensils and appliances
Can they reach dishes, pots and pans, needed
Can they carry foods to the table
Can they clean vegetables and fruits, chop foods, etc..
Shopping
Can they navigate within a shopping facility
Can they lift things from shelves
Can they effectively handle money
Can they store purchases appropriately
Can they carry purchases from store to car and home
Submit
We're all about the Care!
