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This form will help us to better serve your needs.
Prior to learning about your loved one's needs, tell us how they affect you.
How are you related to the person in need of care? ---SpouseDaughter/SonFamily memberFriend
Where does your loved one live? ---In his/her homeIn my homeIn a residenceIn a hospital
How involved are you in the daily needs of your loved one? ---Not at allA littleWhenever necessaryOftenAlways
Other than you, how many people are involved in the daily life of your loved one? ---No one else1 person2 people3 people4 people or more
To better assess the physical limitations of your loved one, please answer the following questions to the best of your knowledge.
Your loved one experiences difficulties when walking? ---NeverRarelySometimesOftenAlwaysI am not sure
Your loved one experiences difficulties when changing bed sheets? ---NeverRarelySometimesOftenAlwaysI am not sure
Your loved one experiences difficulties when bathing? ---NeverRarelySometimesOftenAlwaysI am not sure
Your loved one needs medical assistance? ---NeverRarelySometimesOftenAlwaysI am not sure
Despite having difficulty to perform analytical tasks and experiencing memory loss, one can still enjoy an independant lifestyle. To better assess your loved one's cognitive limitations, please answer the following questions to the best of your knowledge.
Your loved has difficulty in managing his/her appointments? ---NeverRarelySometimesOftenAlwaysI am not sure
Your loved one has difficulty remembering where kitchen ustensils are stored? ---NeverRarelySometimesOftenAlwaysI am not sure
Your loved one has difficulty remembering dates and days of the week? ---NeverRarelySometimesOftenAlwaysI am not sure
When someones suffers from a disease or chronic troubles, it may affect the type of care they need.
Does your loved one suffer from the following: OsteoarthritisCancerConcussionDiabetesHypertensionAlzheimer's diseaseHeart diseaseParaplegia or quadraplegiaNeuromuscular diseaseOther
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