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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.
Additional Information