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Assessment - myself

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

  1. Are there any noticeable changes in your memory?

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

  3. Do you feel sad or lonely most of the time?

  4. Have you withdrawn from regular activities that you once enjoyed?

  5. Do you need assistance when walking, climbing stairs, or getting in and out of bed?

  6. Do you need assistance when dressing, bathing, etc.?

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

  8. Have you noticed changes in your sleep pattern? (i.e. sleeping more or less than usual, disrupted sleep)

  9. Are there any changes in your diet? (i.e. overeating or lack of appetite)

  10. Are you a new or expectant mother?

  11. Are you in the process of transitioning your care from a hospital or medical facility to your home?

  12. Do you take any medications?










  


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