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Home Health Care Assessment
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Home Health Care Assessment
Identify your loved one’s risk factors and determine whether home health care can help by completing the assessment below.
Home Health Care Assessment
1. Does your loved one live alone?
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Yes
No
2. Has he or she previously had home care?
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Yes
No
3. Has he or she had a recent emergency room or hospital visit?
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No recent emergency room or hospital visits
Within the last 30 days
Within the last 6 months
4. Has he or she suffered a fall within the last 3 months, or does he or she have a history of falls?
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Yes
No
5. Has your loved one recently added a new medication, had a change in medication, or raised concerns about his or her medication regimen?
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Yes
No
6. Does he or she take 5 or more different medications?
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Yes
No
7. Has your loved one been diagnosed with any of the following?
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Alzheimer’s/dementia
Other memory-related condition
Stroke
Parkinson’s/MS/ALS
Other movement disorder
COPD or other respiratory condition
Diabetes
Cancer
Back or joint pain
Other pain disorder
Other
None
8. Does your loved one need assistance with daily activities (like bathing, dressing, or grooming)?
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Yes
No
9. Which of the following is difficult for him or her to do alone? (Check all that apply.)
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Bathing
Walking/moving around
Getting dressed
Eating (e.g. trouble swallowing, coughing)
Preparing food
Using the restroom
Driving
Verbal communication
Other
None
10. Does he or she struggle with incontinence?
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Yes
No
11. How easy or hard is it for your loved one to leave home? (Check all that apply.)
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Difficult to get out of bed
Requires a taxing effort
Requires another person’s help
Requires a walker or wheelchair
Difficult, but still gets out frequently
No difficulty leaving home
12. When was your loved one’s last appointment with his or her primary care physician?
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Within the past month
1-3 months ago
More than 3 months ago
Not applicable
13. Do you feel like you need more support and/or information to better care for your loved one?
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Yes
No
14. How old is your loved one?
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Under 55
55 - 64
65 - 79
80 +
15. Is your loved one male or female?
*
Male
Female
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