Preliminary Assessment Tool

Congratulations on taking the first step towards easing your eldercare concerns. Finding appropriate seniors’ housing or in-home care services for an elderly loved one is one of the most daunting tasks you will ever have to undertake, and this is a great start.

To the best of your knowledge, please complete and submit this Preliminary Assessment Tool so that we can provide you with a personalized assessment of your situation.

CONTACT AND GENERAL INFORMATION
Assessment Date: 07/30/2010     Assessment Time: 05:57 PM
Your Contact Information
Full Name:   
Relationship to Client:
Address:
City:
     Province:      Postal Code:
Home Phone:
     Business Phone:     
Mobile Phone:
     Fax:     
* Email:
   Referral Source: Senior CareSelect
* NOTE: Please ensure your email address is correct, as your confirmation that we have
received your assessment information will be sent to this email address.
Client Information
Client Name:   
Date of Birth:

MM
DD
YYYY		 Age: Gender: Male   Female
Address:
City:
     Province:      Postal Code:
Home Phone:
     Mobile Phone:     
Email:   
OVERVIEW AND INTRODUCTION
Client Diagnosis (what is your situation or concern?):
Have you or your loved one had any contact with CCAC or RHA?  
Yes   No   Not Sure
Has your loved one been assessed by CCAC or RHA?
Yes   No   Not Sure
If assessed by CCAC or RHA, what was the outcome?
What, if any, supportive or health-related services are currently being provided to your loved one?
OVERVIEW OF CURRENT LIVING ARRANGEMENTS
1. In what setting does your loved one currently live?
House Apartment
Trailer/Mobile Home Retirement or Assisted Living Residence
Long-Term Care Home Other:
2. Does your loved one own his/her home?Yes   No   Not Sure
3. Does your loved one currently live with...?
Spouse Yourself     Formal Caregiver
Another friend or relative Alone    
4. Is it your loved one's preference to remain in his/her current home?Yes   No   Not Sure
5. Has he/she expressed any desire to explore alternative living arrangements?Yes   No   Not Sure
6. Describe your preference for your loved one's support/care and living arrangements?
GENERAL WELL-BEING AND LIFESTYLE, AT THIS TIME
7. Please indicate which of the following currently applies to your loved one (check all that apply):
difficulty maintaining balance
difficulty walking or getting around
uses an assistive device (e.g walker, wheelchair)
difficulty sitting down or standing from seated
difficulty getting in/out of bed
difficulty getting in/out of the bath tub or shower

difficulty toileting by him/herself
experiences incontinence:   urine   bowel
uses incontinence products

difficulty with balanced and nutritious meal preparation
difficulty with hygiene (e.g. washing, brushing teeth)
difficulty bathing or showering
difficulty grooming and getting dressed or undressed
difficulty taking prescribed medications properly
difficulty with indoor duties (e.g. laundry, housekeeping)

experiences short-term memory loss
       resultant risk of safety issues in home
at risk of wandering from home and/or getting lost
BEHAVIOURAL OBSERVATIONS
8.  Please indicate which of the following applies to your loved one based on your own observations and recent interactions with him/her: (check all that apply):
less active lifestyle and tendency to stay at home     unkempt home interior (e.g. laundry piling up)
exterior of home is less well maintained than usual unexplained weight loss
decline in quality and frequency of contact with
you and/or other family/friends 		blackened pots or other home safety-related risk factors
fewer invites extended to visit his/her home or
change in visit patterns 		bruises or other signs of trauma from falls or
difficulty navigating around the house
unopened bills and other mail piling up    
HEALTH CONDITIONS AND MEDICAL HISTORY
9.  Please indicate which of the following your loved one has been diagnosed with or has experienced
(check all that apply):
Alzheimer Disease or dementia
Arthritis
Cancer
Cerebrovascular problems (strokes)
Chronic pain due to:
Chronic Obstructive Pulmonary Disease (COPD)
Depression
Diabetes 		Falls and related injuries
Hearing impairment
Heart Disease
Osteoporosis
Parkinson's Disease
Respiratory Disease (asthma, trouble breathing)
Visual impairment
Other:
ADDITIONAL COMMENTS
Is there anything else about your loved one's situation that you feel is important to share?
YES, I confirm that the information above is correct and will be submitted to Senior Care Select for follow-up.
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Disclaimer & Privacy Statement
Our preliminary assessment and summary of results are intended for educational purposes only and are not substitutes for a thorough and comprehensive assessment by an eldercare, health or medical professional. Some of the information collected by Senior Care Select is personal data or data which relates to an identifiable person. Examples of personal data are names, addresses, e-mail addresses and telephone numbers. We do not sell personal data to third parties. We use the information you provide when completing the preliminary assessment questionnaire for internal purposes only.