Nursing Home Selection
Considerations Selecting a care provider for a loved
one is a difficult task. However, identifying the particular
needs of your elderly loved one before beginning the
search process will help you explore the available alternatives
and make an informed decision. The following Needs Assessment
Survey will assist you in your search and prepare you
to answer the many questions that will be posed by a
facility's staff. Once completed, click the "submit"
button and a personalized summary report will be generated
that you can use as your "needs" checklist.
Nursing Home Needs Assessment
Survey
Why Do You Need A Nursing Home?
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/quadriplegic
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 nursing home 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 (save to your computer as a text or HTML file first)
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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