Take The 5 Minute In-Home Care Assessment Assess 6 Key Warning Signs & Discover if Your Loved One May Need In-Home Care 1Eating Habits2Personal Hygiene 3Care of Home4Safety/Mental Attitude5Mobility6Behavior Eating HabitsHas there been a change in eating habits? Yes No Is there unexplained weight loss? Yes No Is there food in the home? Yes No Is the person able to go to the grocery store or are groceries delivered? Yes No Personal HygieneAre hygiene and dress taken care of? Yes No Are his or her clothes clean? Yes No Is self-care evident? Yes No Care of HomeIs the home in good order? Yes No Are the lights working? Yes No Is the heat/air conditioning on? Yes No Are the bathrooms clean? Yes No Is the yard overgrown? Yes No Is clutter blocking walkways throughout the house? Yes No Safety/Mental AttitudeIn your opinion, do you feel your loved one is safe in his/her home? Yes No Have there been any recent falls? Yes No Is he/she able to read medicine labels? Yes No Is the older person in good spirits? Yes No Does he/she get unusually fatigued? Yes No Is he/she spending time with friends? Yes No Does he/she enjoy hobbies and activities? Yes No Does he/she get involved in clubs or attend church? Yes No Have friends/neighbors expressed concern? Yes No Have you noticed problems such as burns, injuries, weakness, forgetfulness or possible misuse of prescribed medications? Yes No MobilityDoes he/she have difficulty getting around? Yes No Is there any problem or reluctance to walk? Yes No Is joint arthritis making walking difficult? Yes No Would he/she benefit from a cane or walker? Yes No BehaviorIs the person forgetful or exhibiting inappropriate behavior? Yes No Does he/she seem paranoid or agitated? Yes No Is he/she unusually loud or quiet? Yes No Is he/she making phone calls at all hours? Yes No Are there piles of unopened mail/newspapers? Yes No Are prescriptions going unfilled? Yes No Are appointments being missed? Yes No Is he/she mishandling finances? Yes No Have unusual purchases been made? Yes No Are multiple medications from multiple doctors being taken? Yes No Submit your email below to immediately review your results on the next page.Email(Required) ZIP Code of Loved One(Required) ZIP / Postal Code
