1. The person you are requesting this information for is:
    Self
    Spouse
    Parent
    Sister / Brother
    Grandparent
    Aunt / Uncle
    Child
    Friend
    Other

2. Client's age:

3. When is care needed :
    Immediately
    2-3 weeks
    4-8 weeks
    2-6 months
    6+ months
    Other

4. Support System:

5. How mobile is this person?  
    No problems with mobility
    Stumble from time to time
    Uses a cane or walker for security
    Needs a cane or walker to be mobile
    Uses a wheelchair on occasion
    Needs a wheelchair to be mobile
    Is immobile
    Not certain

    Do not have any personal care needs at this time

    Needs assistance getting dressed and undressed

    Needs assistance getting in and out of bathtub // washing hair / brushing hair
          cleaning teeth / shaving, etc.

    Needs assistance using the commode and/or in contingence management products.
    Not certain

8. Nutritional Needs  
    Able to shop, prepare and maintain a healthy, balanced diet
    Requires assistance with planning, shopping and preparation
    Requires food to be prepared but can eat own meals
    Needs assistance preparing and eating meals
    Requires tubal or intravenous nutrition
    Not certain

9. How often does this person take medication?  
    No prescriptions taken at this time
    One a day
    Two or three per day
    More than 4 per day
    Not certain

10. Home many different medications does this take?
    different medications

11. Home safety environment  
    Able to safely maintain current residence independently
    Needs occasional assistance with outside home maintenance
    Needs frequent help to maintain a safe environment
    Always needs assistance at home with maintenance and safety
    Not certain

12. Cognitive Ability  
    Is aware of surroundings (time, place and person)
    Needs occasional reminders of surroundings
    Needs frequent reminders of surroundings
    Is unaware of surroundings
    Not certain

13. Psychological or mental well-being  
    Psychologically stable, well adjusted and conducts self appropriately
    Exhibits signs of depression, confusion or anxiety
    Exhibits signs of inappropriate behavior
    Other psychological or mental behaviors
    Not certain

14.  Health Problems (check all that apply)
    Arthritis

    Cancer
    Stroke
    Heart disease
    Open wounds
    Alzheimer's or dementia
    Pain
    Parkinson's disease
    Diabetes
    Brain injury
    Lung problem
    Recovering from surgery
    Other
    None

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