Is your loved one safe in their home?
Our goal is to be “Pro-Active in Advance,” helping families to safeguard the seniors in their life.
It may be time for you to consider in-home care. Start by taking our Senior Care Assessment to help you understand whether the time may have come to pursue home care options. Once you have completed the assessment, sit and discuss with family the areas of concern and let Connecting Hearts Home Care work with you for solutions.
Download a PDF Printer-Friendly Senior Care Assessment Form here or view it below.
Senior Care Assessment Tool
1. How much help does your loved one require to get out of a chair or bed?
- Able to move out of a chair or bed alone, easily and safely?
- Need help with one person?
- Need help with two people?
- Needs help but refuses.
2. Does your loved one need help with bathing or personal hygiene?
- They can take care of themselves.
- Often needs hygiene reminders.
- Needs occasional help with bathing or hygiene.
- Needs help daily.
3. How many times a day does your loved one require help in using the bathroom?
- Requires no help.
- Requires some help, 2 or 3 times daily.
- Requires help, 4 to 6 times over a 24-hour period.
- Is unable to manage, is incontinent.
4. Is the individual able to walk?
- Can your loved one walk independently?
- Walk independently using an assistive device, such as a walker or cane?
- Is dependent on one person to help?
- Is wheelchair-bound but can move around independently.
- Is wheelchair-bound and cannot move without help.
- Needs a Hoyer lift, or other device, to get up.
- Can walk, but forgets where he/she is going.
5. For an individual who requires help, what degree of support is available at home?
- Family members/friends provide help on a regular basis.
- Family members/friends proved help, but not consistently.
- Lives alone and does not have any outside help.
- Loved one lives with family member.
- Does not apply to our situation.
6. Is the home situation safe?
- Yes
- No
- Unsure
- Does your loved one answer the door appropriately on their own, or let a stranger into the home?
- Difficulty placing and answering telephone calls?
- Cannot move around the house safely, particularly on the stairs.
- Having difficulty responding to a hazardous situation, such as getting out of the house in an
emergency. - Home is neglected to point of being unsafe.
- May not be able to manage a stove or oven safely.
7. How are meals provided?
- Able to cook independently?
- Relies on family members or friends for meals?
- Does not have reliable support for meals?
- Cooks independently but has difficulty and makes poor nutrition choices.
8. How does your loved one handle medication?
- Can manage medications with no problem.
- Needs help from family or others to take their medications.
- Takes medications by self, but often with mix-ups and confusion.
9. What is the frequency of emergencies (such as falling, illness, sudden agitation) that needs immediate
attention in last 6 months?
- 0 times
- 1-3 times
- Repeated phone calls for emergencies made to family members, or another emergency service.
10. Has there been a change in personality or increased confusion?
- Yes
- Sometimes
- No
- Increasing forgetful.
- Accidents with the car or concerns about driving ability.
- Seems to be increasingly isolated, trouble sleeping, depressed, agitated.
- Trouble coping with daily activities.
- Signs of financial neglect, such as trouble paying bills or managing money.
11. Do you feel confident that you and other family members or friends can continue to provide support
and care as long as necessary?
- Yes, I am confident.
- Yes, I am confident as long as I have more help.
- If loved ones condition worsens, I question whether I will have the energy and/or resources to be
able to provide more care giving. - No, I am already limited in my ability to continue care giving.
- Does not apply to situation.
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