Touch of Love Orientation

Please review the following document and sign below:
Live-In Policy Disclaimer
First Name:
Last Name:
Mobile Phone Number:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number:
Employee Email:
Availability
Type of Transportation you have / will use for home visits:
Do you have any allergies that would affect your work at Touch of Love Home Care Agency?
Please explain your allergies:
Do you have any allergies that would affect your work at Touch of Love Home Care Agency?
Please explain:
How many hours are you willing to work per week?

Work Availability

Rows	Start Time	End Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Health Questionnaire

Do you have any of the following medical conditions?

Rows	No	Yes
Any recent decline in your general health?
Diminished vision/glaucoma
Asthma
Pain, pressure or tightness in the chest
High blood pressure
Change in energy level
Heart trouble
Diabetes
Allergies
Weakness/paralysis
Seizure disorder
Arthritis
Back problems or pain
Fainting, blackout, dizziness
Hepatitis
Neck Problems
Frequent headaches/migraines

If you listed Yes to any of above medical conditions please list any prescribed drug(s) that you currently take:

Do you have any of the following medical conditions?

Rows	No	Yes
Unexplained productive cough
Unexplained weight loss
Unexplained appetite loss
Unexplained fever
Night sweats
Shortness of breath
Chest pain
Increased fatigue
Have been told you have TB
Lived with anyone with TB
Have you been exposed to someone with TB?
Have you left the country in the last 6 months?

Have you had a positive TB Skin test?
When was your most recent chest x-ray?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Do you habitually take any depressants, stimulants, narcotics oralcoholic substances?
Orientation Video
Youtube
Orientation Test
1. Standard precautions protect:
2. A client with a flu should be placed on:
3. To put out electrical fire, you would use:
4. OSHA’s main role in the healthcare workplace is to protect:
5. Of all disasters, the only one you can help prevent is a:
6. Which type of precautions should you follow to prevent COVID-19?
7. A person must develop HIV before they can get AIDS:
8. Only health information is protected. Other information, such as a social security number is not protected information.
9. Which of the following is not a risk factor for falls?
10. A good way to keep elderly clients safe from falls is to:
11. Which of these behaviors might you observe in the patients with Dementia?
12. How can home health aide help Hypoglycemia?
13. Cough lasting longer than 2 weeks, night sweats and loss of appetite are possible signs of Tuberculosis.
14. If needles are recapped, they may be tossed into the household trash.
15. Which hazard poses the greatest safety risk to health care workers?
Correct
Percentage
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Employee Signature:

I agree that the signature will be the electronic representation of my signature for all purposes when I (or my agent) use them on documents, including legally binding documents, just the same as pen-and-paper signature.
primaryPhone
- Full Name
- Date Text
- Initials
- Date Month
- Date Year Digits
- Date Days Digits
- Should be Empty:

Availability

Health Questionnaire

Orientation Video

Orientation Test