The following questionnaire can help you determine the housing or personal care that's best for you or your loved one. Please select the one choice that best describes the situation of the person in need of housing or care. Check only one choice per category. When finished, hit the 'Submit' button.
Can dress independently with clothing appropriate to climate, etc.
Requires assistance or reminders with shoelaces, zippers, garments, hooks, etc.
Dependent on others for dressing.
Can perform all bathing, shaving, and dressing activities without assistance.
Requires assistance or reminders with daily hygiene.
Most or all personal hygiene activities require assistance.
Can move independently. Can inquire about directions and follow them. In case of an emergency, can handle the proper evacuation procedures.
Relies on cane, walker, or wheel chair, but needs help in case of emergency.
Mobile, but may require assistance due to physical problems or confusion.
Needs occasional assistance to move about, but can usually get around independently.
Requires assistance transfering from chair, toilet, or bed.
Requires full transfer and transport assistance, including turning in bed and wheelchair.
Completely continent and independent.
Has incontinence, a colostomy, or catheter, but can take care of themselves.
Occasional problems or requires assistance.
Uncontrollable incontinence and inability to communicate needs.
Able to prepare and eat meals without assistance.
Can perform some meal preparation, but main meal must be prepared by others.
All meals need to be prepared and served by others.
Requires assistance when eating (i.e. pouring, cutting, opening packages).
Totally dependent on others for nourishment, including reminders and assistance.
Can perform housekeeping functions (i.e. bedmaking, vacuuming, cleaning and laundry).
Needs assistance with housekeeping.
Laundry and housekeeping services must be provided by others.
Can handle the self-administration of medications.
Can handle self-administration, but needs reminders or monitoring.
A medication administration system has been arranged with reminders and monitoring.
Licensed personnel must administer medications.
Able to reason. Memory is alright, but has occasional bouts of forgetfulness.
Requires guidance to get around. Has occasional bouts of confusion and disorientation.
Requires orientation assistance and reminders due to poor judgment skills.
Unable to follow directions. Orientation, memory, and judgment skills are severely impaired.
Performs well in a social setting. Emotions are under control.
Requires periodic assistance with coping with stress or other emotional issues.
Requires regular assistance with coping with stress or other emotional issues.
Poses potential for physical injury to self or others. Requires monitoring at all times.
