Expert Resources
Assessment Tool

2. Have you noticed a decrease in your loved one’s energy level? Yes No

You might observe one or more or the following:

• Refuse or avoid social gatherings
• Complaining of being tired or having no energy
• Stopped attending normal outings
• Unsteady on their feet
• Tire after walking short distances Tire after walking short distances
• Decrease in ability to cook or clean

3. Have you noticed a decrease in your loved one’s activity level? Yes No

You might observe one or more or 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 loved one is increasingly overwhelmed or exasperated? Yes No

You might observe one or more or the following:

• Frequent worrying
• Difficulty keeping track of things
• Difficulty caring for things
• Difficulty making or attending appointments
• Difficulty making choices

5. Does your loved one have multiple care needs? Yes No

Multiple care needs is defined as:

• Sees 3 or more physicians
• 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 loved one 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 loved one 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 loved one 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
• Difficulty accepting help
• Complains about change
• Has ever refused medical help

9. Is your loved one 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 what 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
• Feelings of uncertainty