Care Survey

First Name *

Last Name

Date of Birth

What area (location) are you looking for their new home?

Is your loved one a Veteran or spouse of a Veteran?YesNo

Primary Care Physician

Primary Care Physician Phone Number

Are they still driving?YesNoYes, against advice

Are you looking for your own living arrangements or for a family member, loved one, or patient?I am filling in this form for myself and can be contacted at the contact info above.I am filling in this form for someone in my care.

Please fill the details – Name, Phone, Email, Address (if applicable)

Monthly BudgetUnder $1,000$1,000 to $1,500$1,501 to $2,000$2,001 to $3,000$3,001 to $4,000Over $4,000Finding a budget for an assisted living facility is much different than looking at what you can afford for rent. The majority monthly expenses would be included in the rate you pay towards an assisted living facility and would no longer be factored into a monthly budget. We have worksheets and funding resources available to help you figure out a good amount for your circumstance if you’re not sure.

Financial ResourcesI will be selling my home.I have savings.I need help with financial resources.

Height

Weight

If you would like to list details about any conditions or treatments listed above, or any that we missed, please do so here:

HOUSEKEEPING & LAUNDRYIndependentCan perform basic tasks but sometimes needs helpVery light tasks only – can’t maintain acceptable level of cleanlinessAll tasks must be performed by staff

FINANCIAL MANAGEMENTIndependentCan conduct basic transactionsMust be reminded to make deposits, write checks, pay bills, etc.Needs assistance in every transactionRequires a trustee or family appointed guardian to handle all financial arrangements

MEDICATIONSIndependentNeeds medication dosages prepared in advanced but can self-administer on a predetermined scheduleNeeds assistance with storage, preparation, and reminders as to schedulingRequires complete supervision and administration of all medications

MENTAL STATUSOriented in person, place, and time, but may have some occasional forgetfulnessMild impairment – some confusion, difficulty in remembering details in conversationModerate impairment – memory loss, especially of current events – may be anxious and/or agitated; may appear to be functional on surface but detailed conversation reveals problems; strong reminders requiredHeavy impairment in all areas requiring constant orientation; unable to remember personal information; confused as to time and place

WANDERSNo current history of wanderingOccasionally wanders/looks for non-existent place or former residenceWanders during the day on a regular basisWanders in the evening and/or night on a regular basisWanders during the day and night on a regular basis

RESISTIVE BEHAVIORSNo resistive behaviors exhibitedOccasionally exhibits resistive behaviorsFrequently exhibits resistive behaviorsAlways exhibits resistive behaviorsThis can be additionally displayed in disruptive, combative, and/or uncooperative behaviors.

SLEEP DISTURBANCENo problems with sleep (sleeps through the night)Occasionally has problems with sleepFrequently has problems with sleep (wakes constantly)

Please fill out the care survey so we can find out a little more about you.

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