
Self-Assessment
Home healthcare helps adults who need nursing care, rehabilitation therapies or assistance with daily activities enjoy happier, independent lives while remaining in their own homes.
Complete a brief questionnaire to determine if now might be a good time to consider home care for a loved one.
REFLECTING ON THE PAST FEW MONTHS, HAVE YOU NOTICED THAT YOUR LOVED ONE FREQUENTLY:
Experiences trouble communicating with others?
Yes or No
Has challenges getting in and out of bed?
Yes or No
Shows signs of confusion or disorientation?
Yes or No
Wears the same clothes repeatedly without washing?
Yes or No
Has difficulty navigating stairs or moving around the house?
Yes or No
Has cuts or bruises that might be evidence of a fall?
Yes or No
Fails to prepare and eat meals on a regular basis throughout the day?
Yes or No
Does not keep the kitchen stocked with food?
Yes or No
Forgets to take prescribed medications as directed?
Yes or No
Is losing weight?
Yes or No
Neglects personal grooming and hygiene?
Yes or No
Skips showers or baths?
Yes or No
Wears night clothes during the day?
Yes or No
Cannot safely operate a vehicle?
Yes or No
Has withdrawn from friends and other social activities?
Yes or No
Has lack of interests in hobbies and other activities?
Yes or No
Neglects household chores?
Yes or No
Allows mail, newspaper and other clutter to accumulate?
Yes or No
Forgets to pay bills?
Yes or No