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Senior Needs Assessment
Take our Senior Needs Assessment Quiz and get a general recommendation for which type of housing or care may be most appropriate for your loved one.
For each category, please select the description that seems most appropriate right now or in the near future.
At the end of this form, we will request your contact information. It is not required, however; we would like to email your results along with some recommendations to assist in your search.
Safe to be alone without supervision for 24 hours at a time.
Needs regular contact, unsafe to be alone for 24 hours.
High risk of falling. Requires frequent contact and close supervision.
Moves about independently, may use cane or walker. Would be able to evacuate themselves in case of an emergency.
Requires occasional assistance to move about, usually independent, (with or without cane or walker). May need assistance to evacuate themselves in case of emergency.
Requires total assistance with getting up. Would require assistance to evacuate in case of emergency.
Able to prepare own meals. Eats without assistance.
Can prepare simple meals/snacks, but needs assistance with main meal. May have meals delivered.
Unable to prepare meals. May need feeding assistance.
Normal mental function, occasional forgetfulness. Able to identify environmental needs and meet them.
May have occasional confusion. Needs some reminders for orientation. May have Mild Cognitive Impairment or early signs of dementia or Alzheimer’s.
Has an Alzheimer’s or other dementia diagnosis. Requires strong orientation, assistance, and reminders. Memory may be severely impaired.
Independent and completely continent. Or independent in caring for themselves through proper use of supplies.
May have occasional problems with incontinence. May use bedside commode at night or incontinence supplies.. May require assistance in caring for themselves with proper use of supplies.
Incontinent. May be unable to communicate needs.
Able to use phone on their own. 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 a phone on their own.
Responsible for self-administration of medications safely.
Able to self-administer medication or may need to be reminded. Family or nurse may need to arrange medications and provide assistance. May forget to take scheduled medications.
Unable to administer own medications even with supervision.
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, and shopping.
Bathing, Dressing & Grooming
Can independently get bathed, dressed and ready for the day.
May require assistance in a couple of areas.
Dependent on others for more than two areas.
Contact with Medical Providers
Able to set up appointments and visit doctors’ offices as needed.
Chronic health concerns, may benefit from on-site access. Difficulty setting up own appointments and getting to physicians’ offices.
May require oversight of medical personnel on a regular basis.
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