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Home Care Needs Assessment Survey

Alvita Care's Home Needs Quiz

After completing the assessment, we encourage you to consult your physician or other health care advisor.  We also invite you to contact Alvita Care for help in assessing options for maintaining your or your loved one’s independent and dignified lifestyle.

 

 

Begin by clicking Next.

Mobility (Section 1 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Difficulty managing stairs
Unsteady walking or prone to falls
Requires a walker or wheelchair for mobility
Has trouble getting in and/or out of bed

Managing Personal Hygiene (2 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Does not bath and/or groom regularly
Wearing same and/or unclean clothes
Not getting dressed during the day, wearing nightclothes
Requires help to bathe and/or dress

Memory Loss (3 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Misses appointments or commitments
Problems communicating, and forgetting conversations
Disoriented and/or confused about time, places or people
Frequently misplaces items

Taking Medication as Prescribed (4 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Does not take medication or at appropriate times
Takes wrong medication or improper dosage
Requires reminders to take medicine
Unable to re-fill prescriptions as needed

Eating and Preparing Meals (5 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Does not eat regularly, exhibits loss of appetite
Unable to effectively prepare meals
Fails to stock nutritious food
Shows non-diet related weight loss or gain

Toileting / Continence (6 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Requires help toileting
Has accidents at night
Shows frequent need to urinate
Continue to the next section

Clean and Safe Home Environment (7 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Neglects or unable to clean home
Does not wash dishes and/or dispose of trash properly
Allows mail and/or newspapers to accumulate
Not paying bills promptly

Socialization / Depression (8 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Does not regularly socialize / interact with others
Withdraws from society
Shows signs of depression, anxiety or irritability
Continue to the next section

Sleeping Habits (9 of 9)


Have you experienced difficulty with or inability to perform the following tasks?


Unable to sleep
Sleeps excessively
Wakes frequently throughout night

When you are finished the quiz, please fill out the contact information below and click Submit



NameSubjectEmailPhone Number
Note: The information above should not be considered complete and should not be used in place of a visit with, call to, consultation or advice from your Physician or other health care provider
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