Home Health Care Assessment

1. Does your loved one live alone?

2. Has he or she previously had home care?

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3. Has he or she had a recent emergency room or hospital visit?

4. Has he or she suffered a fall within the last 3 months, or does he or she have a history of falls?

5. Has your loved one recently added a new medication, had a change in medication, or raised concerns about his or her medication regimen?

6. Does he or she take 5 or more different medications?

7. Has your loved one been diagnosed with any of the following?

8. Does your loved one need assistance with daily activities (like bathing, dressing, or grooming)?

9. Which of the following is difficult for him or her to do alone? (Check all that apply.)

10. Does he or she struggle with incontinence?

11. How easy or hard is it for your loved one to leave home? (Check all that apply.)

12. When was your loved one’s last appointment with his or her primary care physician?

13. Do you feel like you need more support and/or information to better care for your loved one?

14. How old is your loved one?

15. Is your loved one male or female?

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