Questionnaire
Care Checklist
Complete this checklist to help determine your loved one’s needs.
Does your loved one need help preparing nutritious meals or avoid grocery shopping and cooking?
Does your loved one frequently trip or fall at home, or feel afraid of falling?
Does your loved one forget to take medications, or are medications disorganized or out of date?
Does your loved one need help with one or more household tasks such as cleaning, laundry and paying bills?
Does your loved one seem isolated and alone most of the time, without engaging activities or friends?
Does your loved one seem “down” or depressed at times?
Does your loved one need help with personal care such as dressing, bathing or showering?
Do your loved one frequently seem agitated or aggressive toward caregivers or others?
Has your loved one had frequent car accidents or difficulty driving?
Does your loved one’s home lack proper safety equipment such as grab bars, handrails and an emergency response system?
After completing the questionnaire, consider discussing your results with a Priority Life Care advisor, who can help you explore your options. Contact us and we will help you find helpful resources that may be available to you.
- If you answered “yes” to most of these questions, your loved one may need additional care.
- If you answered “no” to most of these questions, consider talking to your loved one about plans for the future.
These questionnaire results are neither a physician’s diagnosis nor an assessment by a licensed professional. For a professional assessment, schedule a consultation with a Priority Life Care advisor and visit your loved one’s physician.