Assisted Living Assessment Tool

Information About Whom This Plan Is For

* Indicates required field

Whom is this for? *

Name: *

First

Last

Gender: *

Male Female

Date Of Birth: *

Phone Number: *

Current Location and Address: *

Line 1

Line 2

City

State

Zip Code

Country

Your Information

Name: *

First

Last

Spouses Name *

First

Last

Phone Number: *

Email: *

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Client Information

Please read though each question carefully, answer to the best of your ability and knowledge of the potential client.

Reason For Placement: *

Individual can no longer take care of self Individual requires more care than family or friends can provide Individual has medical needs requiring supervision Physician recommended Discharged from hospital but requires temporary skilled care before returning home Other

Other / Reason For Placement: *

Location Preference:

What part of Arizona / The valley would you like them to be in? *

Living Preference: *

Care Home: 5-10 Community: 20-100+

Level Of Assisted Living

SAFETY: *

Safe to be alone without supervision for 24 hours at a time? *Needs Regular contact, unsafe to be alone for more than 24 hours? Has fallen recently or at least 3 times in the past year? Requires frequent contact, may need close supervision?

MOBILITY: *

Does your loved one move about independently, may use cane or walker. Would be able to evacuate self in case of an emergency. *Requires occasional assistance to move about, usually independent. May need assistance to evacuate self in case of emergency. May use cane, walker, or wheelchair. Requires total assistance with getting up. Unable to get assistance in case of emergency.

NUTRITION: *

Able to prepare own meals, Eats without assistance? *Can prepare simple meals/snacks, needs assistance with main meals. May have meals delivered. Unable to prepare meals, May need feeding assistance.

Other / Diet: *

MENTAL STATUS: *

Normal mental function, occasional forgetfulness. Able to identify environmental needs and meet them. *May have occasional confusion, Needs some reminders for orientation. May show early signs of dementia or Alzheimer’s disease. May require strong orientation, assistance and reminders. Memory may be severely impaired.

TOILETING: *

Independent and completely continent, Or independent in caring for self through proper use of supplies? *May have occasional problems with incontinence, May use bedside commode at night. May require assistance in caring for self with proper use of supplies. Incontinent, may be unable to communicate needs.

COMMUNICATION: *

Able to use phone independently, able to look up numbers and receive phone calls without assistance. *Able to call emergency numbers, may need assistance looking up numbers and dialing. May have poor speech. Unable to use telephone independently.

MEDICATIONS: *

Responsible for self-administration of medication safely. *Able to self administer medication or may need to be reminded. Family or nurse may need to arrange medications and assist. May forget to take scheduled medications. Cannot administer own medications even with supervision.

BATHING, DRESSING, AND GROOMING: *

Independent all three areas. *May require assistance with one or two personal activities. Dependent on others for two or more personal activities.

FINANCES: *

Independent. May need some assistance shopping and paying bills. *Difficulty with shopping or performing light housework, Needs assistance with checkbook and paying bills. At high risk for senior fraud. Completely dependent on others for financial matters, housekeeping, shopping.

PHYSICIAN CONTACT: *

Able to set up appointments and visit doctor’s office as needed. *Chronic health concerns, may benefit from on-site access. Difficulty setting up own appointments and getting to physician office. May require oversight of medical personnel on a regular basis.

Other / Medical Conditions: *

Physician Recommended Therapies: *

IV Drugs Medical Supplies Prescriptions Prosthesis

Other / Physician Recommended Therapies: *

Other / Routine Medical Specialists Needed: *

Social & Religious Environment: *

Social butterfly, likes to be the life of the party Enjoys company but likes alone time as well You would prefer they have interaction with other Other

Social & Religious Environment: *

Daily Activites Outside Animals Religion

Other / Social & Religious Environment: *

What if any are their Dislikes/ Deal Breakers: *

Other / Special Needs: *

Legal: *

Does potential resident have a Will in place Does potential resident have (DNR) "Do Not Resuscitate" living will in place Does potential resident have Durable Power of Attorney in place: Healthcare, Mental Health, Financial Does potential resident have a Trust In place Other

Other / Legal: *

End of life: *

Have you decided which Hospice you are going to use? Potential resident have Funeral Arrangements in place Yes, Pre-Paid for my the Funeral Arrangements No, Haven't pre-paid for my funeral arrangements

Comments / End Of Life: *

ASSETS, INVESTMENT AND INCOME TYPE ACCOUNTS

Asset Account Type: *

Current Value: *

Monthly Income: *

Annuity Company: *

Current Value: *

Monthly Income: *

Real Estate/Home Type: *

Mortgage Owed: *

Market Value: *

How Many Policies: *

Annual Premium / Death Benefit: *

Long-Term Care Insurance: *

Yes No

Benefit Amount: *

Health Insurance: Company & type *

Medical Supplies And Equipment / Currently Using

Any Additional Information: *

I agree to receiving marketing and promotional materials

Needs Assessment

Information About Whom This Plan Is For

Your Information

Client Information

Location Preference:

Level Of Assisted Living

ASSETS, INVESTMENT AND INCOME TYPE ACCOUNTS

Medical Supplies And Equipment / Currently Using