When To Step In: An Assessment Tool

The following is a list of questions to ask yourself and/or your loved one. How these questions are answered will give you better insight in determining if assistance is needed. (Hint: the more YES answers, the more indication help is necessary.)

Meals and Nutrition
Is there a loss of interest in preparing meals?	Yes	No
Is there a lack of appetite or loss of interest in eating?	Yes	No
Have food dates on milk or meat expired?	Yes	No
Are there many packages or cans of the same things?	Yes	No
Is there spoiled food in the refrigerator?	Yes	No
TOTAL
Mail and Bills
Is mail piled up unopened or hidden away in drawers?	Yes	No
Are there more than usual magazine subscriptions coming to the home?	Yes	No
Do some of the bills come from unrecognizable sources?	Yes	No
Are there disconnect warnings for utilities including gas, electric and phone?	Yes	No
Have any utilities actually been shut off?	Yes	No
TOTAL
Finances and Banking
Are there new electronic debits showing up on bank statements?	Yes	No
Are there numerous solicitation mailings from different groups? (This could be a sign of frequent giving-often inappropriately.)	Yes	No
Is the checkbook illegible?	Yes	No
Are bank statements being left unreconciled or unbalanced?	Yes	No
Are there frequent checks not being written down?	Yes	No
TOTAL
Memory
Are they missing doctor appointments or forgetting to make them?	Yes	No
Are they making mistakes with their medicines--to much, too little or not taking?	Yes	No
Are they confusing medications in original containers with those laid out on a daily basis?	Yes	No
Are there repeat prescriptions from more than one doctor or pharmacy?	Yes	No
Are foods left cooking on the stove?	Yes	No
Have pots been burned?	Yes	No
Are small appliances being left on?	Yes	No
TOTAL
Falls and Balance
Have there been increased occurrences of falling--with or without injury?	Yes	No
Are medicines causing dizziness or loss of balance?	Yes	No
Are they refusing to use a prescribed cane or walker?	Yes	No
Are there loose rugs or uneven flooring areas in their home?	Yes	No
TOTAL
Sadness and/or Depression
Have been many peer losses recently?	Yes	No
Has the sadness gone on for a long time?	Yes	No
Are they having trouble sleeping or sleeping more than usual?	Yes	No
Have they stopped their usual social activities outside the home?	Yes	No
TOTAL
Driving
Have you noticed a change in their driving capabilities?	Yes	No
Have been recent accidents or problems with driving?	Yes	No
Do they get lost frequently?	Yes	No
Have you noticed changes in their agility, reflexes or eyesight?	Yes	No
Do they get angry or irritable when you bring up a discussion about driving?	Yes	No
TOTAL
Behavior
Is the home as neat and clean as it used to be?	Yes	No
Have they stopped attending church services or beauty/barbershop appointments?	Yes	No
Are they more irritable or otherwise moody, teary or sad?	Yes	No
Have they stopped taking interest in their previously enjoyed hobbies?	Yes	No
Are they no longer in touch with friends either by phone, letters or visits?	Yes	No
TOTAL
Conversation
Do they repeatedly bring up the same issues of concern? (Could be an indication of where they need help but are reluctant to ask for outright.)	Yes	No
Are they having more frequent trouble with "finding the right word"?	Yes	No
Are they using the wrong words?	Yes	No
Do they repeatedly tell the same story, ask the same question etc?	Yes	No
Have neighbors, friends or other relatives spoken to you of their observations or concerns?	Yes	No
TOTAL
*TOTAL FOR ALL* SECTIONS**

Stellar Senior HomeCare, Inc.
A Member of The Senior’s Choice