Care Planning Questionaire

Please Fill out the Care Planning Questionaire below to help you decide if your aging parent or loved one is at risk of mental illness, physical illness or safety issues in their environment and home.

Disheveled appearance?

YES

NO

Wearing the same outfit daily?

YES

NO

Slow to regain health after recent illness?

YES

NO

Isolating?

YES

NO

Saying no to outside activities. Increased social anxiety?

YES

NO

Saying no to outside activities. Increased social anxiety ?

YES

NO

Personal hygiene is compromised?

YES

NO

Housekeeping and laundry is compromised?

YES

NO

Short term memory loss?

YES

NO

Missing meals?

YES

NO

Does Not Answer Phone Calls?

YES

NO

Not taking medication?

YES

NO

Misplacing things?

YES

NO

Repetitive conversation?

YES

NO

Missing appointments can't keep track of dates?

YES

NO

Does not have walk in shower?

YES

NO

Increased fall risk due to clutter?

YES

NO

Loose rugs in home or bathroom?

YES

NO

No longer able to cook safely. Has left stove on?

YES

NO

Risk of being vulnerable to outside predatory people?

YES

NO

Stairs are no longer manageable?

YES

NO

Driving is a concern for potential accident / injury / lawsuit?

YES

NO