Country Manor Senior Living Assessment Survey

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* 2. At what phone number would you like to be contacted?

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* 3. At what email address would you like to be contacted?

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* 4. Who are you assessing today?

Self

Spouse

Parent

Grandparent

Other relative

Friend/Non-relative

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* 5. What is their age?

Under 55

56-65

66-75

76-85

86-90

91-95

96+

Uncertain

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* 6. What is the person’s current living situation?

Lives alone with no assistance

Lives alone with some assistance

Lives with spouse

Lives with you

Lives with family, other than you

Lives in senior living community

Other (please specify)

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* 7. How well does the person complete the following tasks?

	Doesn’t attempt or incapable	Requires assistance of 2 people	Requires assistance of 1 person	Struggles	Performs well
Walking	Walking Doesn’t attempt or incapable	Walking Requires assistance of 2 people	Walking Requires assistance of 1 person	Walking Struggles	Walking Performs well
Bathing	Bathing Doesn’t attempt or incapable	Bathing Requires assistance of 2 people	Bathing Requires assistance of 1 person	Bathing Struggles	Bathing Performs well
Personal Grooming (Hair, Nails, Shaving)	Personal Grooming (Hair, Nails, Shaving) Doesn’t attempt or incapable	Personal Grooming (Hair, Nails, Shaving) Requires assistance of 2 people	Personal Grooming (Hair, Nails, Shaving) Requires assistance of 1 person	Personal Grooming (Hair, Nails, Shaving) Struggles	Personal Grooming (Hair, Nails, Shaving) Performs well
Dressing	Dressing Doesn’t attempt or incapable	Dressing Requires assistance of 2 people	Dressing Requires assistance of 1 person	Dressing Struggles	Dressing Performs well
Toileting	Toileting Doesn’t attempt or incapable	Toileting Requires assistance of 2 people	Toileting Requires assistance of 1 person	Toileting Struggles	Toileting Performs well
Transfers (in/out of chair, on/off toilet, in/out bed)	Transfers (in/out of chair, on/off toilet, in/out bed) Doesn’t attempt or incapable	Transfers (in/out of chair, on/off toilet, in/out bed) Requires assistance of 2 people	Transfers (in/out of chair, on/off toilet, in/out bed) Requires assistance of 1 person	Transfers (in/out of chair, on/off toilet, in/out bed) Struggles	Transfers (in/out of chair, on/off toilet, in/out bed) Performs well
Meal preparation	Meal preparation Doesn’t attempt or incapable	Meal preparation Requires assistance of 2 people	Meal preparation Requires assistance of 1 person	Meal preparation Struggles	Meal preparation Performs well
Medication management	Medication management Doesn’t attempt or incapable	Medication management Requires assistance of 2 people	Medication management Requires assistance of 1 person	Medication management Struggles	Medication management Performs well
Driving	Driving Doesn’t attempt or incapable	Driving Requires assistance of 2 people	Driving Requires assistance of 1 person	Driving Struggles	Driving Performs well
Decision Making	Decision Making Doesn’t attempt or incapable	Decision Making Requires assistance of 2 people	Decision Making Requires assistance of 1 person	Decision Making Struggles	Decision Making Performs well

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* 8. Yes or No Questions (it's okay if you don't know all the answers)

	Yes	No	Unsure
Do they seem depressed, sad or uninterested in life?	Do they seem depressed, sad or uninterested in life? Yes	Do they seem depressed, sad or uninterested in life? No	Do they seem depressed, sad or uninterested in life? Unsure
Have they experienced noticeable weight loss or gain?	Have they experienced noticeable weight loss or gain? Yes	Have they experienced noticeable weight loss or gain? No	Have they experienced noticeable weight loss or gain? Unsure
Do they have toileting accidents – urinary?	Do they have toileting accidents – urinary? Yes	Do they have toileting accidents – urinary? No	Do they have toileting accidents – urinary? Unsure
Do they have toileting accidents – bowel?	Do they have toileting accidents – bowel? Yes	Do they have toileting accidents – bowel? No	Do they have toileting accidents – bowel? Unsure
Are they uncertain, confused or overwhelmed when attempting once-familiar tasks?	Are they uncertain, confused or overwhelmed when attempting once-familiar tasks? Yes	Are they uncertain, confused or overwhelmed when attempting once-familiar tasks? No	Are they uncertain, confused or overwhelmed when attempting once-familiar tasks? Unsure
Do they have an indwelling catheter?	Do they have an indwelling catheter? Yes	Do they have an indwelling catheter? No	Do they have an indwelling catheter? Unsure
Do they use oxygen?	Do they use oxygen? Yes	Do they use oxygen? No	Do they use oxygen? Unsure
Do they constantly repeat the same things over and over?	Do they constantly repeat the same things over and over? Yes	Do they constantly repeat the same things over and over? No	Do they constantly repeat the same things over and over? Unsure
Do they regularly eat well-balanced meals?	Do they regularly eat well-balanced meals? Yes	Do they regularly eat well-balanced meals? No	Do they regularly eat well-balanced meals? Unsure
Do they keep their blood sugar and overall health under control?	Do they keep their blood sugar and overall health under control? Yes	Do they keep their blood sugar and overall health under control? No	Do they keep their blood sugar and overall health under control? Unsure
Do they have any swallowing issues?	Do they have any swallowing issues? Yes	Do they have any swallowing issues? No	Do they have any swallowing issues? Unsure
Are they on a special physician-ordered diet?	Are they on a special physician-ordered diet? Yes	Are they on a special physician-ordered diet? No	Are they on a special physician-ordered diet? Unsure
Do they have significant hearing loss or wear hearing aids?	Do they have significant hearing loss or wear hearing aids? Yes	Do they have significant hearing loss or wear hearing aids? No	Do they have significant hearing loss or wear hearing aids? Unsure

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* 9. Have they struggled with any of the following medical conditions in the past 3 years (check all that apply):

Frequent Falls

Complications from Diabetes

Hospitalization and/or Surgery

Heart Attack or Stroke

COPD

Macular Degeneration or Glaucoma

Hip Fracture

Cancer

Dementia

Alzheimer’s Disease or Parkinson’s Disease

Other (please specify)

Country Manor Senior Living Assessment

Wondering if a loved one needs senior living?

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* 1. What is your name?

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* 2. At what phone number would you like to be contacted?

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* 3. At what email address would you like to be contacted?

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* 4. Who are you assessing today?

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* 5. What is their age?

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* 6. What is the person’s current living situation?

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* 7. How well does the person complete the following tasks?

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* 8. Yes or No Questions (it's okay if you don't know all the answers)

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* 9. Have they struggled with any of the following medical conditions in the past 3 years (check all that apply):

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* 10. Is there anything else you'd like to add about this person's health or living conditions?