COMPETENCY. COMPASSION. COMMUNITY.

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

How well can this person get around?

Is person affected by…
Loss of Eyesight

Is person affected by…
Loss of Hearing

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

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

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

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

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

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

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

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

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

How much help is needed with…
Time to provide care

How much help is needed with…
Knowledge to provide care

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

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

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

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

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