Home Care AssessmentAugust 24, 2018 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 None 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 None 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 None How many falls has your loved one had in the last 3 months? 0 1 2-3 More than three None 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 None 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 None 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 None 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 None Time's up
