Home Care Assessment - Green Tree Home Care

Medical Conditions

Does your loved on have a medical diagnosis that is impacting his or her ability to stay safely at home?

No

Yes, but my loved one is still mostly independent

Yes, my loved one is strongly impacted by an illness or disability

Does your loved one have one or more of the following diagnoses, illnesses, or injuries?

Stroke

Diabetes

Parkinson's disease

Dementia/Alzheimer's disease

Mild cognitive impairment

Any degenerative illness with active symptoms

Loss of mobility or use of limbs

Blindness

None

Cognitive Condition

Is your loved one experiencing cognitive decline?

No, sharp as a tack

No, just a little forgetfulness here and there

Yes, but my loved one manages it pretty well

Yes, my loved one does not make consistently good decisions without direction

My loved one is cognitively fine but some companionship would be really great

My loved one needs help throughout the day but sleeps through the night

Ambulation – Getting Around

Does your loved one need help getting in and out of chairs or bed?

No, my loved one manages just fine

No, but it is slow going

Yes, especially first thing in the morning or later in the day

Yes, my loved one requires assistance with every transfer

My loved is bed ridden

How many falls has your loved one had in the last 3 months?

0

1

2-3

More than three

Medications

What level of medication support does your loved one need?

My loved one self manages medications

Someone else puts pills in a pillbox but my loved one usually remembers to take them daily

My loved one needs daily reminders to take medications as prescribed

My loved one needs medication reminder and depends on medications several times a day

Meals

Select all that apply to your loved one:

My loved one doesn’t need any help with meals

My loved one would love help with the occasional hot meal

My loved one has lost visible weight in the last 6 months and we are worried about nutrition

My loved one is 100% dependent on others for nutrition

Transportation

My loved one needs the following level of transportation support:

None, my loved one drives

My loved one still drives but it would be better if someone else drives

My loved one doesn’t drive but only needs help 1-3 times a week with transportation

My loved one needs almost daily transportation support

My loved one will not use transportation services

Cleaning Support

My loved one needs help with cleaning:

Never, my loved one takes care of house hold chores or there is a cleaning service

Sometimes, a little help with laundry, linens, and tidying up would be great

My loved one needs daily help to clean up after meals or manage daily waste

Personal Care

How much help does your loved one need with showering?

None, my loved one is independent

Standby assist, my loved one can wash but has trouble getting in and out of a slippery tub now and then

My loved one requires help in the shower with washing and personal cleanliness

My loved one relies completely on other for daily personal care and hygiene