1.
The person you are requesting this
information for is:
Mys elf
Parent
Child
Spouse
Uncle / Aunt
Friend
Grandparent
Brother / Sister
Other
2.
Age:
3 .
Is this a mobile person?
4.
Cognitive ability
Aware of environment
Needs to be reminded occasionally
Needs to be reminded frequently
Unaware of the environment
Not sure
5.
Psychological and mental health
Psychologically stable with good conduct and mannerism
Appears depressed, confused or in anxiety
Exhibits misconduct, eg. impoliteness towards others
Not sure
6.
Does he/she have any health problems? (check all that apply)
7.
Home safety
Independent and can maintain the home
Requires frequent assistance maintaining the home
Requires constant assistance maintaining the home
Requires assistance with exterior maintenance
Not sure
8.
Nutritional Requirements
Able to shop, cook, and maintain a healthy diet
Needs help preparing meals, but able to eat
Needs assistance preparing and eating meals
Requires intravenous or tubal means of nutrition
Needs assistance planning, shopping and preparing meals
Not sure
9.
Homemaking requirements (check all that apply)
10.
Personal care requirements (check all that apply)
No care current requirements
Needs assistance getting dressed and undressed
Needs assistance with personal hygiene, eg. bathing,
shaving, teeth
Needs assistance using the restroom
Not sure
11 .
When will personal care be required?
Immediately
2 to 6 months
Other
2 to 3 weeks
6 months to 1 year
4 to 6 weeks
More than 1 year
12.
How many prescription medications does he/she take?
13.
How is the person currently supported?
Living with friends and/or relatives
Living close to friends and/or relatives who
check-in
Friends and/or relatives live at a distance,
yet visit occasionally
Has no current support
14.
Current level of assistance
Not receiving assistance
Receiving assistance through government agency
Receiving assistance from private insurance
Receiving some assistance from family and/or friends
Paying for private assistance
Not sure
Contact Information