Home Health Care Assessment

Take 60 Seconds To Answer 15 Simple Questions.

Identify your loved one’s risk factors and determine whether home health care can help by completing the assessment below.

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1. Does your loved one live alone?*
2. Has he or she previously had home care?*
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?*
Name*

PLEASE DO NOT SUBMIT ANY PERSONAL HEALTH INFORMATION VIA OUR WEBSITE. By providing your email and phone number, you agree to receive updates and communications from Residential Healthcare Group via email and/or text. You may unsubscribe from these communications at any time. Frequency of messaging may vary. Message and data rates apply for any SMS messages. You can opt out from SMS at any time by replying "STOP"

The Home Health Care Assessment is provided for educational purposes only; it is not meant to substitute for the expertise of a trained medical professional. Only a doctor can determine if home health care – or any medication, treatment, or plan of care – is right for your loved one.

If your loved one is currently experiencing a medical emergency, contact your doctor or 9-1-1 immediately.

Caring for a loved one with health challenges can be overwhelming for the entire family – especially if you don’t know where to turn for answers and support.

Call (248) 530-6242 to speak with a Residential nurse about your specific situation.

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