Home Health Care Assessment Test | Helping Hand | Michigan

Home Health Care Assessment Test | Helping Hand | Michigan

Home Health Assessment

Who are you completing this assessment for?

What is the age of the person you are completing this assessment for?

Does this person have a condition that requires visits to a physician at least every 6 months?: Yes No

Has this person been in a hospital, rehabilitation facility, or nursing home in the past 6 months?: Yes No

Does this person take prescription medications?: Yes No

Does this person take all medications correctly?: Yes No

Does this person have any visual difficulties?: Yes No

Can this person read medication labels properly?: Yes No

Does this person have hearing difficulties?: Yes No

Does this person have difficulty communicating needs and ideas verbally?: Yes No

Does this person experience shortness of breath when performing mild activities?: Yes No

Is this person aware of who and where they are?: Yes No

Does this person become confused occasionally?: Yes No

Does this person suffer from memory problems, Alzheimer's, or dementia?: Yes No

Does this person participate in social activities?: Yes No

Has this person ever expressed feelings of depression, sadness, or hopelessness?: Yes No

Has this person ever made statements like, “I don't want to burden my family” or “I feel useless”?: Yes No

Has this person expressed concerns about his/her safety at home?: Yes No

Does this person have a special diet prescribed?: Yes No

Does this person eat at least 2 meals a day?: Yes No

Does this person have difficulty chewing or swallowing?: Yes No

Does this person have difficulty preparing meals?: Yes No

Does this person have difficulty shopping for meals?: Yes No

Is this person able to feed his/her self?: Yes No

Has this person experienced a weight gain or loss of 10 pounds or greater in the past 3 months?: Yes No

Has this person experienced a fall at home in the past 3 months?: Yes No

Does this person have difficulty navigating his/her home?: Yes No

Does this person have an unsteady gait or poor balance?: Yes No

Does this person express a concern about falling at home?: Yes No

Does this person use an assistive device such as a walker or cane?: Yes No

Is this person wheelchair bound?: Yes No

Is this person bed bound?: Yes No

Does this person have difficulty using the tub or shower or require assistive devices for bathing?: Yes No

Does this person have difficulty changing positions (sitting to standing for example) or require the assistance of a person or device?: Yes No

Does this person have urinary or bowel incontinence?: Yes No

Does this person have open sores (wounds or bedsores)?: Yes No

Does this person require bathing assistance?: Yes No

Does this person require assistance for dressing or grooming?: Yes No

Can this person drive independently?: Yes No

Can this person perform daily housekeeping independently?: Yes No

Can this person perform shopping independently?: Yes No

Does this person have any of the following conditions? Heart disease, Lung disease, Cancer, Arthritis, Alzheimer's/Dementia, Joint replacements, Diabetes, Stroke: Yes No