Senior Care Assessment Tool from WNYSeniorCare.org

Senior Care Assessment Tool for Family Caregivers

This questionnaire is designed to help family members assess the situation of caring for an elderly loved one. It is not intended to be a recommendation for a specific program of care; rather, it should provide a basis for discussion with the family, a physician or other health provider if you believe the caregiving situation needs to be improved.

Choose the answer that applies to the situation generally or most of the time.

1. How much help does the individual require to get out of a chair or out of bed?	Able to move out of a chair or bed alone, easily and safely Needs one person to help Needs two people to help Needs help but refuses it or does not get enough help regularly
2. Does the individual need help with bathing or personal hygiene?	Can take care of self Often needs hygiene reminders Needs occasional help with bathing or hygiene Needs help daily
3. How many times a day does the individual require help in using the bathroom?	Requires no help Requires some help, 2 or 3 times daily Requires help, 4 to 6 times over a 24-hour period Is unable to manage, is incontinent
4. Is the individual able to walk?	Can walk independently Independently uses assistive device, such as a walker or cane Is dependent on one person to help Is wheelchair-bound but can move around independently Is wheelchair-bound and cannot move without help Can walk, but forgets where he/she is going
5. For an individual who requires help, what degree of support is available at home?	Family members/friends provide help on regular basis Family members/friends provide help, but not consistently Lives alone and does not have any outside help Does not apply to our situaiton
6. Is the home situation safe?	Yes Unsure No For example, have you noticed any of the following: The individual may not answer the door appropriately on their own, or let a stranger into the home The individual cannot place and answer telephone calls The individual cannot move around the house safely, particularly on stairs The individual would have difficulty responding to a hazardous situation, such as getting out of the house in the event of an emergency or fire The home has been neglected to the point of being unsafe/the neighborhood is increasingly unsafe The individual may not be able to manage a stove or oven safely
How are meals provided?	The individual is able to cook independently The individual relies on family members or friends for meals The individual relies on other outside resources, such as home-delivered meals The individual does not have reliable support for meals The individual cooks independently but has difficulty and/or makes poor nutrition choices
8. How does the individual handle medications?	The individual can manage medications with no problems The individual needs help from family or others The individual takes medications by self, but often with mixups and confusion
9. What is the frequency of emergencies (such as falling, illness or sudden agitation) that need immediate attention, or hospitalizations, in the past 6 months?	0 times 1-3 times There are repeated phone calls for emergencies made to family members, 911, or another emergency service
10. Have you witnessed a change of personality in the individual or increased confusion?	Yes Sometimes No For example: The individual seems to be increasingly forgetful There have been accidents with the car or there have been concerns about driving ability The individual seems to be increasingly isolated, depressed, agitated or has trouble sleeping The individual seems to be increasingly fearful of new situations or surroundings The individual has trouble coping with daily activities There are signs of financial neglect, such as trouble paying bills or managing money
11. As a caregiver, do you feel confident that you and other family members or friends can continue to provide support and care for this individual as long as it is necessary?	Yes, I am confident Yes, I am confident as long as I have more help If the individual’s condition worsens, I question whether I will have the energy and/or resources to be able to provide more caregiving in the future No, I am already limited in my ability to continue caregiving at this level, and there is no one else to help me Does not apply to our situaiton
12. Please provide your Zip Code (optional)	Must be 5-digit US Zip Code Only

If you have answered all questions, please click on the Submit Assessment button below.