| HEARTS AT HOME SENIOR CARE’S TEST |
| HOW DO YOU KNOW IF SOMEONE NEEDS HELP? |
| Scoring: |
1 = Strongly Disagree |
2 = Disagree |
3 = Agree |
4 = Strongly Agree |
|
|
| My loved one is in control of their mental faculties |
|
| Do they act impulsively |
1 |
2 |
3 |
4 |
| Are they able to recall time, place and local |
1 |
2 |
3 |
4 |
| Are they forgetting to take their medications |
1 |
2 |
3 |
4 |
| Are they forgetting to keep or make appointments |
1 |
2 |
3 |
4 |
| Do they pay their bills on time |
1 |
2 |
3 |
4 |
| Are they withdrawn or depressed |
1 |
2 |
3 |
4 |
| Are they still active in their social events |
1 |
2 |
3 |
4 |
| Do they call you frequently for assistance |
1 |
2 |
3 |
4 |
|
| My loved one is in control of their physical functions: |
|
| Able to prepare meals |
1 |
2 |
3 |
4 |
| Able to feed self |
1 |
2 |
3 |
4 |
| Able to dress self |
1 |
2 |
3 |
4 |
| Able to toilet self |
1 |
2 |
3 |
4 |
|
| My loved one is safe: |
|
| No vehicle accidents (even small ones) |
1 |
2 |
3 |
4 |
| Gets lost driving or walking |
1 |
2 |
3 |
4 |
| Leaves pots and pans on stove still cooking |
1 |
2 |
3 |
4 |
| Allow strangers in the house/Lock themselves out |
1 |
2 |
3 |
4 |
|
| Is you’re loved at risk for a fall: |
|
| Are they taking four or more medications |
1 |
2 |
3 |
4 |
| Do they have a history of falling |
1 |
2 |
3 |
4 |
| Do they use an assistive device to walk |
1 |
2 |
3 |
4 |
| Have they been hospitalized in the past 12 months |
1 |
2 |
3 |
4 |
|
| Scoring |
| 0-40 points minimal assistance needed |
| 41-60 points’ moderate assistance needed |
| 61-80 points’ high-level assistance needed |
