COMPETENCY. COMPASSION. COMMUNITY.

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Are you looking for care for yourself or a loved one?

Self Loved One

How well can this person get around?

Walks independently Can walk short distances without support Use of a cane or walker is always necessary Can move independently with a wheelchair Needs assistance in wheelchair

Is person affected by…
Loss of Eyesight

No Loss Mild Loss Moderate Loss Complete Loss

Is person affected by…
Loss of Hearing

No Loss of Hearing Mild Loss, Uses Hearing Aids Moderate Loss, Uses Hearing Aids Complete Loss

Diabetes, Heart Disease, or other chronic condition
How severely does this condition affect Mental Condition

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Diabetes, Heart Disease, or other chronic condition
How Severely does this condition affect Physical ability

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Diabetes, Heart Disease, or other chronic condition
How Severely does this condition affect Mood

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Degenerative disorder (i.e. Alzheimer’s, Dementia, ALS/Lou Gehrig’s Disease, Parkinson’s)
How severely does this condition affect Mental Condition

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Degenerative disorder (i.e. Alzheimer’s, Dementia, ALS/Lou Gehrig’s Disease, Parkinson’s)
How Severely does this condition affect Physical ability

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Degenerative disorder (i.e. Alzheimer’s, Dementia, ALS/Lou Gehrig’s Disease, Parkinson’s)
How Severely does this condition affect Mood

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Other condition that affects Mental/physical/mood
How severely does this condition affect Mental Condition

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Other condition that affects Mental/physical/mood
How Severely does this condition affect Physical ability

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

Other condition that affects Mental/physical/mood
How Severely does this condition affect Mood

Mildly Mildly to Moderately Moderately Moderately to Severely Severely

How much help is needed with…
Time to provide care

Help is always Available with family and friends Help is sometimes Available with family and friends We need a solution the provides occasional care We need a solution the provides more than occasional care We need a solution the provides total care

How much help is needed with…
Knowledge to provide care

We’re completely knowledgeable – just don’t have time We’re somewhat knowledgeable – but have very little time We have very little knowledge – but do have time We have no knowledge – with lots of time We have no clue how to provide this care

How much help is needed with…
IADLs: Shopping, Cooking, managing medications, housework, laundry, driving

We’ve got that stuff covered We could use a bit of help We could use more than a bit of help We could use quite a bit of help We can’t do any of it

How much help is needed with…
ADLs: Shopping, Cooking, managing medications, housework, laundry, driving

We’ve got that stuff covered We could use a bit of help We could use more than a bit of help We could use quite a bit of help We can’t do any of it

How much help is needed with…
How frequently do you need extra help overnight

Always Weekly Seldom Never

How much help is needed with…
What percentage of care cannot be completed without a therapist, nurse, or other medical practitioner

0% 25% 50% 75% 100%

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