Resources

Assess Your Situation

Have you noticed something negatively effecting a senior’s independence and quality of life? This assessment tool will help you gauge the situation.

1.	Are you seeing a decline in physical and/or mental ability or does your friend or family member have trouble with self-care?	Yes No
	Are you observing one or more of the following?	Change in their hygiene routine Clothing is dirty Wearing the same clothes day after day They have body odor They are losing weight Their fridge is empty

2.	Have you noticed a decrease in your friend or family member’s energy level?	Yes No
	Are you observing one or more of the following?	Refuse or avoid social gatherings Complaining of being tired or having no energy Stopped attending normal outings Unsteady on their feet Tire easily after walking short distances Decreased ability to cook or clean

3.	Have you noticed a decrease in your friend or family member’s activity level?	Yes No
	Are you observing one or more of the following?	Lack of energy Lack of desire Inability to attend Feelings of being overwhelmed Inability to navigate stairs, walking distance

4.	Have you noticed your friend or family member is increasingly overwhelmed or exasperated?	Yes No
	Are you observing one or more of the following?	Frequent worrying Difficulty keeping track of things Difficulty caring for things Difficulty making or attending appointments Difficulty making choices

5.	Does your friend or family member have multiple care needs?	Yes No
	Multiple care needs is defined as:	Has 3 or more physicians attending to them Sees a physical, occupational, or speech therapist regularly Has 3 or more diseases Takes 5 or more medications each day Has forgetfulness, Alzheimer’s or dementia

6.	Are you unsure if your friend or family member is safe in their current living situation?	Yes No
	You might observe one or more or the following:	Declining vision Difficulty walking or unsteady on their feet Complaints of dizziness Has fallen within the last year Experiences shortness of breath or becomes winded easily Has increasing forgetfulness Is blue or frequently sad

7.	Is your friend or family member experiencing increasing isolation?	Yes No
	You might observe one or more or the following:	Complains of being alone or lonely Physically unable to go out Does not want visitors Death or severe illness to close friends or family Sleeps longer than 9 hours a day Refuses outings

8.	Is it hard for your friend or family member to make choices?	Yes No
	You might observe one or more or the following:	Difficulty admitting their health has changed Difficulty making changes to their routine Difficulty limiting self Difficulty asking for help Complains about change Has ever refused medical help

9.	Is your friend or family member having trouble maintaining their optimal health and independence?	Yes No
	You might observe one or more or the following:	Frustrated with limitations Difficulty with chronic pain Difficulty paying bills Difficulty balancing checkbook Difficulty keeping home clean Difficulty driving Increasing severity or number of medical conditions Increasing severity or frequency of symptoms

10.	Are you unsure what help is available or where to turn to for help?	Yes No
	You might be experiencing these difficulties or emotions:	Unsure services are needed Unsure what services are available Unsure of eligibility for services Unsure of costs Unsure if insurance will pay Unsure where to turn Feelings of guilt Feelings of stress Feeling uncertainty

Q4 TIPS & TOOLS