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Assessment - A Friend or loved one

Please fill out the following assessment to see if you could benefit from our services:

  1. Are there any noticeable changes in your friend/loved one's memory?

  2. Are there visible changes in your friend/loved one's physical appearance? (i.e. weight gain or loss, wearing the same clothes daily, overall disheveled appearance)

  3. Does your friend/loved one feel sad or lonely most of the time?

  4. Has your friend/loved one withdrawn from regular activities that he or she once enjoyed?

  5. Does your friend/loved one need assistance when walking, climbing stairs, or getting in and out of bed? 

  6. Does your friend/loved one need assistance when dressing, bathing, etc.?

  7. Are there activities around their home that your friend/loved one need and/or want help with? (i.e. running errands, housekeeping, preparing meals)

  8. Has your friend/loved one noticed changes in their sleep pattern? (i.e. sleeping more or less than usual, disrupted sleep)

  9. Are there any changes in your friend/loved one's diet? (i.e. overeating or lack of appetite)

  10. Is your friend/loved one a new or expectant mother?

  11. Is your friend/loved one in the process of transitioning their care from a hospital or medical facility to their home?

  12. Does your friend/loved one take any medications?





 
 
 
 





  


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