Assessment

Needs assessment tool

The needs assessment tool helps us to customize care options specific to the needs of our clients. Please select the description that is most appropriate.

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*First Name		*Last Name
*Email Address		Title
Company		Address
Address 2
City		State/Zip
*Phone		Fax

QUESTIONNAIRE
MOBILITY/AMBULATION		COGNITION/MENTAL STATUS
yes  no	WALKS UNASSISTED.	yes  no	NORMAL MENTAL FUNCTION. NO CLINICAL DIAGNOSIS OF MENTAL ILLNESS.
yes  no	RELIES ON A CANE, WALKER OR WHEEL CHAIR AND MAY NEED HELP IN AN EMERGENCY.	yes  no	SHORT TERM MEMORY LOSS/CONFUSED AT TIMES. NEEDS REMINDERS FOR MEALS AND ACTIVITIES.
yes  no	NEEDS "STAND BY" ASSISTANCE DUE TO MEDICAL OR PHYSICAL PROBLEMS.	yes  no	DEMENTIA DIAGNOSIS.
yes  no	REQUIRES ONE PERSON TO ASSIST WITH TRANSFERING FROM CHAIR, TOILET, OR BED.	yes  no	ALZHEIMERS DIAGNOSIS.
yes  no	REQUIRES 2 PEOPLE TO ASSIST WITH TRANSFERING FROM CHAIR, TOILET, OR BED.	yes  no	TRAUMATIC BRAIN INJURY OR ACQUIRED BRAIN DISORDER.
TOILETING		BATHING, DRESSING & GROOMING
yes  no	COMPLETELY CONTINENT.	yes  no	CAN PERFORM ALL ACTIVITIES WITHOUT ASSISTANCE.
yes  no	HAS OCCASIONAL PROBLEMS WITH INCONTINENCE OR REQUIRES ASSISTANCE WITH CARE.	yes  no	REQUIRES ASSISTANCE WITH ONE OR TWO ACTIVITIES.
yes  no	INCONTINENT.	yes  no	MOST OR ALL PERSONAL HYGIENE ACTIVITIES REQUIRE ASSISTANCE.
NUTRITION		NIGHT TIME NEEDS
yes  no	EATS WITHOUT ASSISTANCE.	yes  no	SLEEPS THROUGH THE NIGHT.
yes  no	MAY NEED SOME ASSISTANCE AT MEALS.	yes  no	NEEDS HELP WITH TOILETING.
yes  no	TOTALLY DEPENDENT ON OTHERS FOR NUTRITIONAL NEEDS. MAY NEED FEEDING ASSISTANCE.	yes  no	UP 3 OR MORE TIMES DURING THE NIGHT.
yes  no	SPECIAL DIETARY REQUIREMENTS	yes  no	STAFF TO VISUALLY CHECK ON LOVED ONE 2 OR 3 TIMES DURING THE NIGHT.
DIABETIC		MEDICATION MANAGEMENT
yes  no	CONTROLLED WITH MEDICATIONS.	yes  no	CAN SAFELY IDENTIFY AND ADMINISTER ALL MEDICATIONS.
yes  no	CAN SELF INJECT INSULIN IF PREFILLED BY STAFF.	yes  no	NEEDS OCCASIONAL REMINDERS TO SELF ADMINISTER MEDICATIONS.
yes  no	SPECIAL DIET REQUIRED.	yes  no	REQUIRES STAFF SUPERVISION FOR MEDICATION MANAGEMENT.
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