Needs assessment


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?

Where does your loved one live?

How involved are you in the daily needs of your loved one?

Other than you, how many people are involved in the daily life of your loved one?

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?

Your loved one experiences difficulties when changing bed sheets?

Your loved one experiences difficulties when bathing?

Your loved one needs medical assistance?

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?

Your loved one has difficulty remembering where kitchen ustensils are stored?

Your loved one has difficulty remembering dates and days of the week?

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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