Call for a Complimentary Consultation
|
Lancaster 717.394.5111
|
York: 717.600.8600
Care services & cost
Cost of care
Client customized care options
Specialty care
Hospice care
Dementia care
Determining your needs
Home care quiz
Home care needs assessment
Care considerations form
Testimonials
FAQs
Caregiver registration
Blog
Contact
Menu
☰
Care services & cost
Cost of care
Client customized care options
Specialty care
Hospice care
Dementia care
Determining your needs
Home care quiz
Home care needs assessment
Care considerations form
Testimonials
FAQs
Caregiver registration
Blog
Contact
Homecare needs
assessment
Use this form to assess what tasks or personal care needs your loved one may need currently.
Include your loved one in this assessment if able.
Name
*
Email
*
Phone
*
Task/Activity
Level of Help Needed
None
Some
A Lot
Bathing:
Sponge Bath
None
Some
A Lot
Shower
None
Some
A Lot
Full Bath
None
Some
A Lot
Dressing (putting on clothes)
None
Some
A Lot
Grooming (hair, shave, teeth)
None
Some
A Lot
Assistance with Walking (a person must help):
Uses Walker
None
Some
A Lot
Uses Wheelchair
None
Some
A Lot
Uses Cane
None
Some
A Lot
Getting in and out of bed/chair
None
Some
A Lot
Assistance with going to toilet
None
Some
A Lot
Incontinence Care (adult briefs, catheter)
None
Some
A Lot
Meal Preparation:
Arrange food on a place, cut food
None
Some
A Lot
Place food in mouth
None
Some
A Lot
Other:
Medication Reminders (remind of times to take pills)
None
Some
A Lot
Medication Organization (sort/place pills in dispenser)
Not Applicable
Socializing (how much are they interacting w/ others)
None
Some
A Lot
Shopping (groceries, clothes)
None
Some
A Lot
Light Housekeeping
None
Some
A Lot
Doing Laundry
None
Some
A Lot
Handling the mail
None
Some
A Lot
Scheduling Doctor's Appointments
None
Some
A Lot
Providing Transportation (driving)
None
Some
A Lot
Managing Medications (order refills)
None
Some
A Lot
Managing Money (pay bills)
Not Applicable
Handling Household Chores (garbage, repairs)
None
Some
A Lot
Handing Health Insurance Matters
None
Some
A Lot
Number of Hours can be left alone
CAPTCHA
