Country Manor Senior Living Assessment

Wondering if a loved one needs senior living?

It can be difficult to tell. This simple quiz will help you identify if your loved one could benefit from assisted living, memory care, or other senior living options - or if they aren't quite ready.
1.What is your name?(Required.)
2.At what phone number would you like to be contacted?
3.At what email address would you like to be contacted?(Required.)
4.Who are you assessing today?
5.What is their age?
6.What is the person’s current living situation?
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
Bathing
Personal Grooming (Hair, Nails, Shaving)
Dressing
Toileting
Transfers (in/out of chair, on/off toilet, in/out bed)
Meal preparation
Medication management
Driving
Decision Making
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?
Have they experienced noticeable weight loss or gain?
Do they have toileting accidents – urinary?
Do they have toileting accidents – bowel?
Are they uncertain, confused or overwhelmed when attempting once-familiar tasks?
Do they have an indwelling catheter?
Do they use oxygen?
Do they constantly repeat the same things over and over?
Do they regularly eat well-balanced meals?
Do they keep their blood sugar and overall health under control?
Do they have any swallowing issues?
Are they on a special physician-ordered diet?
Do they have significant hearing loss or wear hearing aids?
9.Have they struggled with any of the following medical conditions in the past 3 years (check all that apply):
10.Is there anything else you'd like to add about this person's health or living conditions?
1 / 1
100%
Privacy & Cookie Notice