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Basic Assessment Details
Seeking level of care for my
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Mom
Dad
Grandpa
Grandma
Brother
Sister
Uncle
Aunt
Friend
Relative
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My {user_slug} is
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Under 55
55-65
66-75
76-85
86-95
Over 95
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(Page 2 of 12)
My {user_slug}
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Lives home alone with no assistance
Lives in home with help from a relative
Lives in home with professional care
Lives in a nursing home
Lives in an assisted living
Lives in an independent living
Is in a day care program
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(Page 3 of 12)
My {user_slug} needs
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Is independent and needs no help
Some help with meal preparation
Some help with shopping
Some help with medications
Some help with grooming, dressing, bathing, walking and transfers
Lot of help with grooming, dressing, bathing, walking and transfers
Need around-the-clock medical and nursing care
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(Page 4 of 12)
My {user_slug} needs
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No assistance with laundry
Assistance with laundry
No assistance with cleaning
Assistance with cleaning
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Has your {user_slug} had a recent fall?
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Not at all
No, but there is some unsteadiness
Yes, but occasionally(Two falls a year)
Yes, and frequently(> two falls a year)
Unsure currently
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(Page 6 of 12)
My {user_slug} uses
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No device for mobility
Use a cane
Use a walker
Use a rollator
Use a wheelchair
Use a scooter
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(Page 7 of 12)
My {user_slug}
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Has age related memory loss
Moods are appropriate to the circumstance
Has no psychosocial diagnosis
Has no cognitive impairment diagnosis
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(Page 8 of 12)
My {user_slug} is
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Likely to forget names of friends and family
Likely to forget to turn the stove off
Likely to get lost in the neighborhood or familiar places
Sometimes unable to use the phone, TV remote and thermostat
Likely to exercise poor judgement
Sometimes forget to eat and drink
Sometimes forget to take medications timely
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(Page 9 of 12)
My {user_slug}
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Has early signs of forgetfulness
Has a diagnosis of mild Dementia
Has a diagnosis of moderate to severe Dementia
No diagnosis of Dementia
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(Page 10 of 12)
My {user_slug} has some psychosocial concerns such as
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Confusion
Agitation
Combativeness
Wandering
Elopement
Anxiety
Depression
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(Page 11 of 12)
The following is very important for my {user_slug}(Prioritize based on your preference)
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Three meals a day
Availability of snacks
Activities 7 days a week
Access and availability of rehabilitation services such as PT, OT and ST
Round the clock nursing
Round the clock care givers
Travel to area restaurants, malls
Cognitive care programs
Falls program
Incontinence program
Wound care
Hospice care
Clean living unit and clean community
Frequent and timely communication from the community
Availability of WiFi
Availability of phone
Ability to face time
Able to visit anytime
Frequent well-being check
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(Page 12 of 12)
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