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Preferences


About Your Loved One


1 2
Yes No
Yes No
Paying for adequate care
Convincing my loved one that a change is required
Getting all family members in agreement on what to do
Finding the right facility that meets my loved one/s unique needs
Other

Budget


Private funds (income or savings)
Long-term care insurance
TRICARE (military)
Medicare/Medi-Cal
Supplemental Security Income (SSI)

Activities of Daily Living


Activity Accomplishes Alone Needs
Some Help
Needs
Much Help
Bathing
Getting Dressed
Feeding Self
Eating a nutritious diet
Walking
Using the toilet
Getting out of bed or a chair
Taking medications
Competency Good Moderate Poor
Health
Mobility
Balance
Memory
Managing daily activities
Managing medications
Decision making
Managing finances
Unique Care Yes
Needs an assistive device to get around (walker, wheelchair)?
Uses an electric scooter?
Has been diagnosed with Dementia or Alzheimer's Disease?
At risk of wandering or exiting without the needed supervision?
Takes medications for mental health issues (Bi-Polar, Schizophrenia, Depression)?
Needs help from a licensed professional to administer injections?
Has severe vision impairment or is blind?
Has severe hearing impairment or is deaf?
Can't control when they urinate?
Can't control when they have a bowel movement?
Uses a feeding tube?
Has a colostomy or pouch to collect waste from the body?
Has a urinary catheter?
Is a smoker?
Needs oxygen therapy or uses a device to get oxygen?
Needs a ventilator?
Has a tracheotomy tube?
Has a bandaged wound someone else needs to take care of?
Bedridden or bed bound?
Is overweight or obese?
Insists on bringing a small pet?

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