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Online Assessment Form
In-Home Care in Metro Dallas, Texas
* = Required Information
1. Family Support
My loved one has easy access to a caring support system of family and friends that he/she can rely on for daily assistance with physical, financial, and emotional needs. These family members and friends can provide this support willingly, without compromising their own daily lives and schedules.
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Always
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Sometimes
Almost Never
Never
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* = Required Information
2. Mobility
My loved one is very mobile and can walk indoors and outdoors easily, without falling. He/she can get into and out of bed, chairs, showers and tubs easily, and can climb stairs without slipping or pausing. He/she can safely operate an automobile and navigate city streets and highways.
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Always
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Almost Never
Never
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* = Required Information
3. Memory
My loved one has a good memory and can remember the names and personal histories of loved ones. He/she can remember to perform important daily tasks such as locking doors, turning off stove burners, taking medications, etc.
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Always
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Almost Never
Never
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* = Required Information
4. Medical
My loved one can follow medical directions consistently and read prescriptions correctly. He/she can manage a complex daily prescription regimen and take all of the proper medications without supervision.
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Always
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Almost Never
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* = Required Information
5. Meal Preparation
My loved one can cook for himself/herself on a regular basis, shop for groceries without assistance, and keeps the home well-stocked with fresh and healthy foods.
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Always
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* = Required Information
6. Personal Hygiene
My loved one showers or bathes regularly and keeps clothing laundered and fresh. He/she pays attention to personal hygiene and personal appearance as much as he/she did five years ago.
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Always
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* = Required Information
7. Home Safety
My loved one's home offers a safe environment for living and socializing; my loved one keeps it clean, well heated and cooled, and free from pests. The house is free from clutter and hazards (loose rugs, exposed wiring, slippery tile, uneven surfaces, etc.), and my loved one would know what to do in the case of an emergency.
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Always
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* = Required Information
8. Social Interactions
My loved one is active and can socialize with others both inside and outside the home. He/she maintains the same level of social activity and friendships that he/she did five years ago.
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Always
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Almost Never
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* = Required Information
Contact Information
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Phone Number
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Email Address
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