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Assessment - A parent or relative

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

  1. Are there any noticeable changes in your parent/relative's memory?

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

  3. Does your parent/relative feel sad or lonely most of the time?

  4. Has your parent/relative withdrawn from regular activities that he or she once enjoyed?

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

  6. Does your parent/relative need assistance when dressing, bathing, etc.?

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

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

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

  10. Is your parent/relative a new or expectant mother?

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

  12. Does your parent/relative take any medications?


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