Personal Assessment

Selecting a care provider for a loved one is a difficult task.  However, identifying the particular needs of your elderly loved one before beginning the search process will help you explore the available alternatives and make an informed decision.  The following Personal Needs Assessment Survey will assist you in your search.

  Once completed, click the "submit" button and a personalized summary report will be emailed back to you within 24 hours.

Client Assessment/Profile

Ambulation:
No Assistance
Stand-by Assistance Needed
Fall Risk
Cane
Walker
Wheelchair
Electric Wheelchair/Scooter

Mental Status:
Alert
Oriented x3
Slightly forgetful
Short term memory loss
Confused
Very confused
Dementia
Alzheimer's
Combative
Wanders
Demanding
Depression
Sleeps through night
Awake at night

Incontinent:
Continent
Incontinent Bladder
Incontinent Bowel
Needs toileting

Requires Assistance with:
Dressing
Bathing
Grooming/hygiene
Medication
Transferring
Feeding
Laundry

Assistive Devices:
Eyeglasses
Dentures
Hearing aid
Prosthesis
Raised toilet seat

Impairments:
Speech
Hearing
Vision
Arthritis
Parkinson's
Diabetic
Insulin dependent
Emphysema
Alcohol history
Stroke/CVA
Left side weakness Right side weakness
High blood pressure

Diet:
Regular
No added salt
No concentrated sweets
Chopped
Mechanically softened

Oxygen:
O2 concentrator
Liquid O2
PRN

Waivers & Exceptions for RCFE:
IPPB Machine
Colostomy
Illeostomy
Enema/suppository, fecal impaction removal
Indwelling urinary catheter
Injections
Dermal ulcer (stage 1 or 2)
Hospice

Medications:
List any and all medications currently taken:

Location:
City preferred First Choice
City preferred Second Choice

Location is near family and friends?

Financial - How will you pay for care?
Private Pay (Retirement, Assisted Living & Skilled Nursing)
Amount budgeted for care $
Medicare (Skilled Nursing only)
Medicaid/Medical (Skilled Nursing only)
Private long-term care insurance (Assisted Living & Skilled Nursing)

Legal:
Does the individual have a will?                            Yes    No
Durable power of attorney for Health Care?         Yes    No

Contact Information:
Contact Name: 
Street Address: 
City, State & Zip: 
Contact telephone: 
Contact E-mail: 

Patient Information (Optional)
Patient Name:
Relations to you: 
Age:     Female    Male

Thank you for taking the time to complete this Personal Assessment, you will receive within 24-hours a Personalized Summary Report.  Should you have any question, always feel free to contact our office at (866) 227-9676.

Thank you,