Home Health Care Assessment "*" indicates required fields 1. Does your loved one live alone?* Yes No 2. Has he or she previously had home care?* Yes No 3. Has he or she had a recent emergency room or hospital visit?* No recent emergency room or hospital visits Within the last 30 days Within the last 6 months 4. Has he or she suffered a fall within the last 3 months, or does he or she have a history of falls?* Yes No 5. Has your loved one recently added a new medication, had a change in medication, or raised concerns about his or her medication regimen?* Yes No 6. Does he or she take 5 or more different medications?* Yes No 7. Has your loved one been diagnosed with any of the following?* Alzheimer’s/dementia Other memory-related condition Stroke Parkinson’s/MS/ALS Other movement disorder COPD or other respiratory condition Diabetes CHF or shortness of breath Cancer Back or joint pain Other pain disorder Other 8. Does your loved one need assistance with daily activities (like bathing, dressing, or grooming)?* Yes No 9. Which of the following is difficult for him or her to do alone? (Check all that apply.)* Bathing Walking/moving around Getting dressed Eating (e.g. trouble swallowing, coughing) Preparing food Using the restroom Driving Verbal communication Other 10. Does he or she struggle with incontinence?* Yes No 11. How easy or hard is it for your loved one to leave home? (Check all that apply.)* Difficult to get out of bed Requires a taxing effort Requires another person’s help Requires a walker or wheelchair Difficult, but still gets out frequently No difficulty leaving home 12. When was your loved one’s last appointment with his or her primary care physician?* Within the past month 1-3 months ago More than 3 months ago 13. Do you feel like you need more support and/or information to better care for your loved one?* Yes No 14. How old is your loved one?* Under 55 55 - 64 65 - 79 80 + 15. Is your loved one male or female?* Male Female Name* First Email* Phone*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"
