What is the client's current living situation? * ? (e.g., living alone, with family, independent living community)
What prompted the consideration of an assisted living facility? * ? (e.g., recent fall, increasing difficulty with daily tasks, loneliness, caregiver burnout)
What are the primary concerns or challenges the client is currently facing? *? (Please describe in detail)
If different from client, or if client needs assistance with decision-making
Are you legally authorized to make decisions for the client? *? If yes, please specify (e.g., Power of Attorney, Guardianship):
List any current medications. *? (including over-the-counter and supplements)
Does the client have any allergies? *? (medication, food, environmental)
Does the client have a history of falls? *? If yes, please describe:
Does the client have any cognitive impairment? *? (e.g., dementia, Alzheimer's) If yes, please describe the stage/severity:
Does the client require assistance with any of the following Activities of Daily Living (ADLs)? * ? (Please check all that apply and indicate level of assistance: Independent, Some Assistance, Full Assistance)
Does the client require assistance with any of the following Instrumental Activities of Daily Living (IADLs)? * ? (Please check all that apply and indicate level of assistance: Independent, Some Assistance, Full Assistance)
Does the client require any specialized medical equipment? *? (e.g., oxygen, wheelchair, walker)
Are there any current behavioral issues or wandering concerns? *? If yes, please describe:
What is the client's approximate monthly income? ? (e.g., Social Security, pension, investments)
What financial resources are available for assisted living? ? (e.g., savings, long-term care insurance, sale of home)
Does the client have long-term care insurance?? If yes, provider and policy number:
Is the client eligible for or currently receiving any government benefits?? (e.g., Medicaid, VA Aid & Attendance)
Are there any specific dietary needs or preferences? ? (e.g., diabetic, vegetarian, low-sodium)
Does the client have any pets? ? If yes, type and size:
What is the client's preference regarding the size of the community? ? (e.g., small, medium, large)
What is the client's preference regarding location?? (e.g., near family, quiet area, urban setting)
What types of activities or amenities are important to the client?? (e.g., religious services, exercise classes, social events, library)
Veteran Status * ? If yes, branch and dates of service
