Assisted Living Facility Selection Considerations
Explanation copy goes here
Assisted Living Facility Needs Assessment Survey
Why Do You Need A Assisted Living Facility?
Individual can no longer care for him/herself
Individual
requires more care than can be provided by our family
Individual
has extensive medical needs
Physician
recommendation
Discharged from hospital and requires temporary skilled care before
returning home
Individual Currently Has The Following Medical Needs
(Check as many as apply)
Nursing Care Level Requirements
Supervision only
Assistance
with daily living activities
Therapy
24-hour nursing
Intensive nursing
Other
Medical Conditions
Alzheimer's disease
Cancer
Cardiovascular disease
Chronic pain
Dementia
Developmentally
disabled
Head trauma
Hematologic condition
Mental disease
Neurological disease
Neuromuscular disease
Orthopedic/skeletal
problems
Pulmonary disease
Para/quadrapalegic
Stroke
Trauma
Wound
Other
Therapies Recommended By Physician
Physical therapy
Occupational therapy
Speech therapy
Respiratory therapy
Reality therapy
Other
Equipment and Supplies
Wheel chair
Prosthetics
Ventilator
Special bed
Intravenous drugs
Prescription drugs
Medical supplies
Oxygen
Other
Other Medical Specialists Needed on a Regular Basis
Dentist
Dietician
Opthamologist
Physician
Podiatrist
Other
Individual Requires Help With The Following Activities of Daily Living
Personal care
Bathing
Continence
Dressing
Eating
Mobility
Toileting
Using the telephone
Shopping
Preparing meals
Housekeeping
Laundry
Transportation
Taking medications
Handling finances
Other
Cultural and Social Needs
Special Needs
Language (if not English)
Culturally-based
special diet
Medically
prescribed special diet
Other
Religion
Religious affiliation
Social activities preferred
Cards and games
Movies
Prayer groups
Arts and crafts
Television
Reading
Pet therapy
Social events
Outdoor activities
Interaction with
others
Other
Facility Preferences
Private room
Semi-private room
Small facility (Less than 100
beds)
Medium facility ( 101 to 300
beds)
Large facility (over 300 beds)
Family Needs
Family is
current care provider
Is home-based
care an option?
Is respite care
(part-time assisted living facility care) an alternative?
Is adult day care an
option?
Family lives in town
Family lives out of
town
Location
Location is near family and
friends?
Near a hospital?
Near
a doctor's office or clinic?
Financial - How Will You Pay For Care?
Private pay
Medicare
Medicaid
Veteran's benefits
Private
long-term care insurance
HMO or managed care
Other
Transportation
Who will transport the individual to off-site appointments if necessary?
Family will provide Facility must provide
Legal
Does the individual have a will? Yes No
Is a durable power of attorney in place? Yes No
Any life support directives? Yes No
Does the individual have a living will? Yes No
Patient Information (optional*)
Contact Information (optional*)
* Summary generated from this form may be printed out and sent or E-mailed to a care
facility. This information will not be stored on our server or used for any other purpose.
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