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Care Services
24-Hour Care
Assisted Living
Specialty Care
Home Care Quiz
Hospice Care
Dementia Care
Testimonials
FAQs
Caregiver registration/Be a Caregiver
Caregiver Registration Form
Blog
Contact
Assessing Your Loved One Checklist
Use this form to assess what tasks or personal care needs your loved one may need currently.
Name
*
Email
*
Phone
*
Task/Activity
Level of Help Needed
None
Some
A Lot
Bathing:
Sponge Bath
None
Some
A Lot
This is a description
Test
Shower
None
Some
A Lot
Full Bath
None
Some
A Lot
Dressing (putting on clothes)
None
Some
A Lot
Grooming (hair, shave, teeth)
None
Some
A Lot
Assistance with Walking (a person must help):
Uses Walker
None
Some
A Lot
Uses Wheelchair
None
Some
A Lot
Uses Cane
None
Some
A Lot
Getting in and out of bed/chair
None
Some
A Lot
Assistance with going to toilet
None
Some
A Lot
Incontinence Care (adult briefs, catheter)
None
Some
A Lot
Meal Preparation:
Arrange food on a place, cut food
None
Some
A Lot
Place food in mouth
None
Some
A Lot
Other:
Medication Reminders (remind of times to take pills)
None
Some
A Lot
Medication Organization (sort/place pills in dispenser)
Not Applicable
Socializing (how much are they interacting w/ others)
None
Some
A Lot
Shopping (groceries, clothes)
None
Some
A Lot
Light Housekeeping
None
Some
A Lot
Doing Laundry
None
Some
A Lot
Handling the mail
None
Some
A Lot
Scheduling Doctor's Appointments
None
Some
A Lot
Providing Transportation (driving)
None
Some
A Lot
Managing Medications (order refills)
None
Some
A Lot
Managing Money (pay bills)
Not Applicable
Handling Household Chores (garbage, repairs)
None
Some
A Lot
Handing Health Insurance Matters
None
Some
A Lot
Number of Hours can be left alone
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