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Senior Care Assessment Tool

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Mobility
Transportation
Nutrition
Hygiene
Housekeeping
Dressing
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Medication
Memory
Emotions
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The following assessment tool can help you determine which type of housing or care is best for you or your loved one.

Who is this for?

Yourself

Your loved one

Please select at least one of the options.

Important Notice

Important Notice: This senior assessment tool is for use as a guideline only. Caregivers, seniors and others should consult with health and social professionals, and the care facilities themselves, to make an appropriate choice.

How independent are you when it comes to moving around your home?

I am very mobile and need no assistance to move around, and I would be able to evacuate in case of emergency.

I am independent, but I use a cane, walker, or wheelchair, and I might need help if there was an emergency.

I am usually independent, but I do need help occasionally with getting in or out of bed, up or down stairs, or getting up from sitting down.

I need some help regularly because of confusion, poor vision, weakness or a lack of motivation, but I can walk and move around.

I need help most or all of the time when moving around.

What level of independence do you have for transportation and getting around town?

I own a car and can drive myself safely.

I use public transportation or other transportation options independently.

I am independent, but I need occasional assistance with certain tasks or trips.

I need assistance with planning trips, giving directions, carrying personal items, or with handicap access.

I need full transportation services provided.

How independent are you when it comes to preparing meals and eating?

I am able to prepare my own meals and eat independently.

I can eat and prepare my food, but I would prefer to have my meals prepared.

I can eat, and I can do some meal preparation, but I may need help with tasks like opening packaging, reaching in the pantry, and lifting dishes.

I need my meals prepared, occasional reminders to eat, or help with tasks such as cutting food.

I often need reminders and/or assistance with meal preparation and eating.

How independent are you when it comes to personal hygiene tasks?

I am independent in all personal care.

I occasionally need reminders or light assistance, but I am usually very independent.

I regularly need reminders, or need help performing some tasks, such as getting into a bathtub or shaving.

I can do some things, but I need assistance or reminders with personal care due to confusion or lack of motivation.

I need help with all or most personal hygiene tasks.

How independent are you when it comes to housekeeping tasks?

I can clean and maintain my home independently.

I can clean, but I need help occasionally with home maintenance.

I can clean my home, but I may need help with home maintenance or heavy housekeeping, such as vacuuming, laundry and changing linens.

I need some help with cleaning (heavy and light tasks), and I sometimes need reminders or directions.

I need full laundry and housekeeping services provided.

How independent are you with dressing yourself?

I am independent in dressing.

I can dress myself, but sometimes I need help with certain tasks, such as shoelaces, zippers, medical appliances or garments.

I can dress myself, but I always need help with tasks, such as shoelaces, zippers, medical appliances or garments.

I can dress myself, but I need reminders to help pick out the right clothes, and to help with some other clothing tasks.

I need assistance with dressing and undressing.

Describe your independence in continence and toileting tasks:

I am independent when using the restroom, and I do not have continence issues.

I have regular incontinence, a colostomy or catheter, but I can care for myself through the proper use of supplies.

I occasionally need help when using the restroom, or with incontinence, colostomy or catheter care.

I need help using the restroom, or with management of incontinence through the proper use of supplies.

I am regularly and uncontrollably incontinent, and/or dependent on someone for this type of care.

How independent are you in managing and administering medications?

I manage and administer my own medications.

I am able to self-administer medications, but I sometimes need reminding or monitoring.

I use a medication administration system set up by my caregiver, or a health agency that provides reminders and monitoring.

I cannot, will not or do not have authority to administer my own medications even with supervision.

My medications must be administered by licensed personnel.

How is your memory and mental orientation?

I know where I am all the time, my memory is good, and I am able to make decisions, plan and organize daily events.

I have occasional problems with forgetting time, place and people, and I sometimes need a hint or two to get my memory working.

Occasionally, I forget time, place or people; need direction or guidance in getting from place to place; or have occasional confusion that makes me anxious, social withdrawn or depressed.

I am quite forgetful nowadays. I often forget how to do things, or I have difficulty with regular confusion that makes me anxious, social withdrawn or depressed.

I always confuse time, place and person, or my memory is severely impaired. I am not able to follow directions.

How would you describe your behavior in dealing with emotions and others?

I can deal with emotions, cope with stress, and act appropriately in public and with friends.

I believe I can act appropriately in public, deal with my emotions and cope with stress, but others have reported that I may need some outside assistance.

Occasionally, I need help expressing my emotions appropriately; resolving conflicts or coping with stress, and others have to intervene, but not often.

I usually need help from others to resolve conflicts, cope with stress, or with expressing my emotions appropriately, and I have overreacted with anxiety, withdrawal, depression or agitation in the past.

Managing my behavior or emotions is a regular consideration for those who assist me. I have been uncooperative or abusive to past aides, or need regular emotional guidance.

How independent is your loved one when it comes to moving around their home?

Very mobile with no assistance needed. Capable of moving about and able to evacuate in case of emergency independently.

Independent with cane, walker, or wheelchair, but may need help in an emergency.

Usually independent, but requires occasional assistance with getting in or out of bed, up and down stairs, or getting up from sitting down.

May require some assistance due to confusion, poor vision, weakness or poor motivation.

Requires transfer and transport assistance. Requires turning in bed and in wheelchair.

What level of independence does your loved one have for transportation and getting around town?

Owns and operates a car independently and safely.

Able to use public transportation or other transportation options independently.

Needs occasional assistance with tasks or trips, but largely independent.

Needs assistance with planning trips, giving directions, carrying personal items, or with handicap access.

Needs full transportation services provided.

How independent is your loved one when it comes to preparing meals and eating?

Able to prepare own meals and eat meals without assistance.

Able to eat and prepare own meals, but prefers to have meals prepared.

Eats independently, but may need assistance in meal preparation tasks like opening packaging, reaching in the pantry, and lifting dishes.

Needs all meals prepared, needs occasional reminders to eat or help with tasks such as cutting food.

Often needs reminders and/or assistance to eat, and needs meals prepared.

How independent is your loved one when it comes to personal hygiene tasks?

Independent in all personal care.

Occasionally needs reminders or light assistance, but is usually very independent.

Require reminders regularly, or regular help with tasks like getting into the bathtub or shaving.

Needs assistance or reminders with personal care regularly due to confusion or lack of motivation.

Dependent on others for most or all personal hygiene tasks.

How independent is your loved one when it comes to housekeeping tasks?

Independent in housekeeping, including bed making, vacuuming, cleaning and laundry.

Able to clean but occasionally needs help with maintenance.

Able to clean, but needs help with home maintenance or heavy housekeeping, such as vacuuming, laundry and changing linens.

Needs some help cleaning (heavy and light tasks), and sometimes need reminders or directions.

Needs full laundry and housekeeping services provided.

How independent is your loved one when it comes to dressing his or herself?

Independent and dresses appropriately.

Can dress self but sometimes needs help with certain tasks, such as shoelaces, zippers, medical appliances or garments.

Can dress self but regularly needs help with tasks, such as shoelaces, zippers, medical appliances or garments.

Can dress self but regularly needs reminders to help choose appropriate clothing, or to help with other various tasks.

Maybe needs assistance with dressing and undressing.

Describe your loved one's independence in continence and toileting tasks:

Independent and completely continent.

Has incontinence, a colostomy or catheter, but is able to care for self through the proper use of supplies.

May need occasional support when using the restroom, or with incontinence, colostomy or catheter care.

Needs help with toileting, or is unwilling or unable to manage incontinence through the proper use of supplies.

Regularly and uncontrollably incontinent, dependent or unable to communicate needs.

How independent is your loved one in managing and administering medications?

Responsible for management and self-administration of medications.

Able to self-administer medications, but others may need to remind and monitor the process.

Family or home health agency has arranged a medication administration system with reminders and monitoring by family members or others.

Cannot administer own medications even with supervision.

Medications must be administered by licensed personnel.

How is the memory and mental orientation of your loved one?

Oriented to person, place and time. Memory is intact with no pattern of memory loss. Able to reason, plan and organize daily events.

Memory is good but occasionally needs hints in remembering time, place and people. Memory loss does not impact daily life.

Occasionally forgets time, place or people; needs direction or guidance getting around or performing complex tasks; or has occasional confusion that causes anxiety, social withdrawal or depression.

Judgment and memory may be poor. May not attempt tasks that are within capabilities. May regularly experience confusion that causes anxiety, social withdrawal or depression.

Disoriented to time, place and person, or memory is severely impaired. Usually unable to follow directions.

How would you describe your loved one's behavior in dealing with emotions and others?

Deals appropriately with emotions, copes with stress in a healthy way, and deals appropriately with others.

Largely capable of acting appropriately in public, and dealing with emotions and stress, but there are signs that occasional intervention may be needed.

Requires periodic intervention to express emotions, cope with stress, or resolve conflicts.

Regular intervention may be required in expressing emotions, in dealing with stress, or in dealing with periodic outbursts of anxiety, withdrawal, depression, or agitation.

Intervention is required to manage behavior. May pose physical danger to self or others, or is abusive or unacceptably uncooperative.

Please select an answer before continuing.

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