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We can’t help being concerned about those we care about, especially when they are aging or have just experienced an illness, incident, or hospital stay. Many wonder if they are being overprotective, or if their loved one really does need assistance. A Caring Touch’s care assessment offers you the opportunity to see if your worries are justified by looking at specific issues of everyday living. You can use this assessment for your own benefit, or you can e-mail it to A Caring Touch to receive our initial suggestions based upon your response.

Click here to download a PDF version of the form.

If your loved one is still able to live independently, we hope we can ease your mind. If we feel that your loved one truly needs assistance, we are happy to explain the areas in which we can help.

 

1. Is your loved one currently taking any medication?



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a. If so, are they able to fully understand and follow the prescription instructions?



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b. Are you very confident that they are taking the correct dosage at the correct time?



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c. Could this medication that they are taking affect their physical or mental state if avoided or taken in excess?



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2. Does your loved one follow recommendations give by their physician?



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3. Is your loved one able to drive or walk to obtain necessary home supplies, i.e. groceries, soap, medicine?



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4. If above is answered "No", is there a reliable system set in place to assure that your loved one has basic home needs met?



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5. Is your loved one able to answer the telephone without inconvenience?



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6. Is your loved one able to make phone calls out at anytime of the day or night?



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7. Is your loved one able to pay bills, such as power and water, in an accurate and timely manner?



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8. Does your loved one have a neighbor, friend, or family member close-by that is willing, able, and accessible to assist your loved one in person if called upon?



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9. Is your loved one able to prepare their meals on their own?



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a. If so, are you concerned that they are getting the proper nutrition given what they are preparing?



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b. Is there a chance that a burner or oven could be left on when preparing meals?



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10. Does your loved one tend to get weaker when they get tired?



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11. Is your loved one able to bathe themself independently?



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12. Do you feel comfortable with their bathing facilities?



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13. Is your loved one able to successfully use the bathroom independently?



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14. Are they able to either do laundry or coordinate laundry services?



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15. Are you ever concerned about your loved one's appearance, i.e. hair, dress, oral hygiene?



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16. Does the physical layout of your loved one's home, i.e. stairs, decorations, rugs, cause you to be concerned about safety?



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17. Have you noticed any memory loss with your loved one?



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18. If above is answered "Yes", does this seem to be increasing or decreasing?



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19. Do you sometimes feel that your loved one is not supplying you with accurate or clear information in regard to their own health?



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First Name

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Last Name

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Email *

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Phone Number *

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Subject

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Questions/Comments

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315 N. Center St. | Bloomington, Illinois 61701

A Caring Touch of McLean County, Inc., Home Health Services, Bloomington, IL


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