Hospice Care Assessment Home Health Care Assessment Quiz Step 1 of 9 11% Has your mom, dad or loved one been diagnosed with any of these conditions? Heart failure or other heart condition Stroke Diabetes COPD or other respiratory condition Dementia or neurological condition Cancer Other Have they experienced any of the following in the past 3 months? Serious illness (pneumonia, infection, flu) Joint replacement or surgery (knee, hip, shoulder, etc.) Falls, dizziness or loss of balance Trouble eating or swallowing Depression Amputation Has your loved one been diagnosed with a terminal condition, with six months or less life expectancy? Yes No Not Sure Has their doctor prescribed any of the following medications or treatments? Anti-clotting or blood thinning medication Diabetic medication or treatment Pain Medication IV Medication Dialysis Oxygen Other Does your loved one have trouble keeping track of which medications they’re supposed to take, or have they accidentally taken the wrong medication or dosage? Frequently – Several times a month Regularly – At least once a month Sometimes – A few times a year Rarely – Once a year or less Don't know Do they have difficulty performing any of the following tasks? Bathing Getting dressed Preparing food Using the restroom Grocery Shopping Driving How often do they visit or call the doctor to deal with symptoms of their condition or side-effects from medication? Frequently – Several times a month Regularly – At least once a month Sometimes – A few times a year Rarely – Once a year or less Don't know How difficult is it for your loved one to leave home?Please select the option that best describes their current situation. Their condition makes it very difficult or impossible to even leave bed. Leaving home requires a lot of effort that exhausts them. They leave home infrequently and briefly because of the difficulty. They use a walker, wheelchair, or require another person’s help to leave home. They have some difficulty leaving home, but not enough to stop them from going somewhere. They have no di All Done! See Your Results: Fill out the form to see your results and get our guide, 'Complete Guide to Understanding Home Health', for free!First NameLast NameEmail Are you ready to connect with us about care? Yes No By submitting your information, you agree to receive email and telephone communications from us in accordance with our terms and privacy policy. You can opt out of these communications at any time.
