Who is the person you are inquiring about?For example: Why are we asking about the specific individual's relationship to your loved one, to better understand their context and needs?MomDadHusbandWifeGrandpaGrandmaFriendSomeone ElseAge:What age group does your loved one fall into, and why is age relevant in assessing their situation?For example: Age is an important factor for understanding potential health considerations.50-6566-7071-7575-8586-100Behavioral and Psychological Symptoms:Are there noticeable shifts in mood, irritability, or other psychological symptoms, and why are these important to consider?For example: Yes, there have been noticeable changes in mood and increased irritability, which may indicate underlying issues. Please check all that apply below:Shifts in mood, increased irritability, or apathyNoticeable changes in personality or social interactionsAlterations in sleep duration or qualityFrequent disturbances during the nightActivities and Interests:What sort of activities would your loved one will be interested in receiving from the caregivers, and do you wish to add any other activities in their daily schedule?For example: The older adult loves to do oil painting, enjoys reading different books and likes practicing yoga at times.Please check all the desired below:BingoBridgeChessDrawingEuchreJigsawSewingWalkingWritingYogaWeightsKnittingQuiltingReadingScrabbleCanastaDominoesJoggingSculptureSolitaireSwimmingCheckersCrochetingOil PaintingCeramicsGin/RummyNeedlepointOil PaintingWord SearchWatercolorsMisc. CraftsWoodworkingBackgammonScrapbookingGroup ClassesWord ScrambleCaregiver Support:How much support does your loved one receive from caregivers, and why is this relevant in understanding their situation?For example: The older adult receives 24/7 caregiver support due to challenges in managing daily tasks independently.Please check all that apply below:24/710-20 hoursMore than 20 hoursNo family or outside help providedCognitive Function:Are there any changes in your loved one's cognitive function, and why is assessing cognitive function crucial?For example: Cognitive function has declined, with difficulties in recalling recent events and decision-making. Please check all that apply below:Changes in short-term or long-term memoryDifficulty recalling recent events or names of familiar peopleChallenges in decision-making or problem-solvingChanges in planning or organizing daily activitiesDifficulty finding the right words or expressing thoughtsChanges in writing or speaking abilitiesAwareness of time, place, and current eventsConfusion about the day, date, or seasonCurrent Living Situation:Where does your loved one currently reside, and how does this impact their daily life and care?For example: The loved one is currently living in assisted living, which provides some level of support but may not be sufficient. Please check all that apply below:Living with spouseLiving home aloneAssisted LivingMemory CareLiving with family or relativeLiving with a friendDaily Functioning:What challenges does your loved one face in managing daily tasks, and why is this important to assess?For example: Challenges include difficulties in managing self-care tasks, such as bathing and dressing. Please check all that apply below:Difficulties in managing self-care tasks, such as bathing, dressing, or eatingChallenges in handling finances or managing medications independentlyDaily Routine:How does your loved one spend their day, and why is understanding their daily routine valuable?For example: Your loved one spends a significant amount of time watching TV and requires assistance with daily activities.SleepEatingWatching TVHousehold WorkFood preparation and cleanup:Lawn and garden care:Religious activities:Volunteer activities:Reading:Grooming:Readiness for Memory Care Now due to:Is the loved one ready for memory care, and what specific concerns or challenges are driving this consideration?For example: Yes, considering safety and security concerns, as well as challenges in managing caregiving in the current setting. Please check all that apply below:Safety and Security ConcernsElopement behaviorCaregiver issuesCaregiving not manageable in the current settingFinancial and Medical Readiness:How prepared is the family, financially and medically, for the loved one's potential move to memory care?For example: Financial resources have been planned, and there is a Power of Attorney for both financial and medical affairs. Please check all that apply below:Power Of Attorney over Financial and Medical affairsFinancial resources planning doneNeed help in this area?Other Situations Affecting the Family Member:Are there other health or lifestyle situations affecting the family member, and why do these matter in the assessment?For example: The loved one is experiencing medication management issues and frequent wandering, impacting overall well-being. Please check all that apply below:Medication managementWanderingSundowningDepressionWeight Loss due to not getting proper mealsUTI infectionsFallsIncontinenceNot enough hydrationSleep DeprivationSocial and Environmental Factors:How are social and environmental factors impacting the loved one, and why are these factors considered?For example: Social withdrawal and recent accidents at home indicate a need for additional support and safety measures. Please check all that apply below:Withdrawal from social activities or loss of interestChanges in relationships with family and friendsRecent accidents or safety concerns at homeIssues with wandering or getting lostContact Information:NamePhoneEmail AddressNote:After we review your responses, we will get in touch with you. Thank you!Submit