What type of home do you currently live in? *? (e.g., single-family house, condo, apartment)
How long have you lived at your current address? *? (e.g., 6 months, 2 years, 15 years)
Who else lives with you in your home? *? (e.g., spouse, adult child, roommate, caregiver)
Why do you want to continue living in your current home? *? (e.g., like the neighbourhood, want to stay near friends, home feels safe)
Do you have any concerns about living at home? *? (e.g., stairs are difficult, fear of falling, safety at night)
Do you currently receive any in-home assistance? *? (e.g., daughter visits daily, paid caregiver twice a week, meal delivery service)
Please list your current medical diagnoses or conditions? *? (e.g., diabetes, high blood pressure, arthritis)
Please list all medications you are currently taking (including over-the-counter and supplements). *? (e.g., Metformin 500 mg, Vitamin D supplement)
Do you have any allergies? (medication, food, environmental) *? (e.g., penicillin, peanuts, pollen)
Have you had any recent hospitalizations or emergency room visits? *? (e.g., admitted for pneumonia last month, ER visit for chest pain in June)
Have you experienced any falls recently? *? (e.g., slipped in bathroom last week, two falls in the past six months)
Do you have any cognitive concerns? *? (e.g., memory issues, difficulty concentrating, confusion)
How much assistance do you currently need with Activities of Daily Living (ADLs)? *? (e.g., bathing, dressing, toileting, eating, transferring, continence)
How much assistance do you currently need with Instrumental Activities of Daily Living (IADLs)? *? (e.g., meal preparation, housekeeping/tidying, managing medications, transportation, shopping, using telephone/technology, managing finances)
Do you use or need any specialized medical equipment? *? (e.g., oxygen, wheelchair, walker, hospital bed)
Do you have any behavioral or wandering concerns? *? (e.g., restlessness at night, tendency to leave home, aggressive behavior)
Are there any areas in your home that feel unsafe or difficult to navigate? *? (e.g., stairs, slippery floors, poor lighting)
Do you have safety features in your bathroom? * ? (e.g., grab bars near toilet or shower, non-slip mats)
Is your home accessible for mobility devices? * ? (e.g., wider doorways, ramps, stair lifts)
Are your smoke and carbon monoxide detectors working? * ? (e.g., tested monthly, replaced batteries recently)
Do you have a personal alert system in case of emergencies? * ? (e.g., Medical Alert, wearable emergency button)
How is your home maintenance and repairs managed? * ? (e.g., family member does repairs, hire professionals, some repairs unmet)
Do you feel safe in your neighborhood? * ? (e.g., yes, mostly; no, due to crime or lighting issues)
How often do you interact with family, friends, or neighbors? * ? (e.g., daily, weekly, rarely)
Do you feel socially connected? * ? (e.g., yes, very connected; somewhat connected; not connected at all)
Are you involved in any social groups, clubs, or religious organizations? * ? (e.g., church group, local club, senior center, volunteer group)
Who would you contact in an emergency? (Please list emergency contacts) * ? (e.g., spouse, adult child, neighbor, friend)
Do you have reliable transportation for appointments, errands, and social activities? * ? (e.g., personal car, public transit, rides from family, community transport service)
What is your approximate monthly income? ? (e.g., $1,200/month from Social Security and pension)
Do you have financial resources available for care or home modifications? ? (e.g., savings, long-term care insurance, reverse mortgage)
Do you currently have long-term care insurance? If yes, please describe. ? (e.g., policy covers in-home support up to $150/day)
Do you receive or qualify for any government benefits? ? (e.g., Medicaid, VA Aid & Attendance, Medicare Advantage in-home support benefits)
What types of support or services are you interested in exploring? * ? (e.g., caregiver assistance, meal delivery, transportation, home modifications, medical equipment)
What are your primary goals for this assessment? * ? (e.g., stay in my home safely, reduce fall risk, get more help with daily activities)
Is there any additional information you’d like to share to help us better understand your needs? * ? (e.g., special preferences, family concerns, unique circumstances)
Veteran Status * ? If yes, branch and dates of service
