Assessment Checklist

Physical health

• Make note of these factors; you may need the help of your loved one’s doctor.

• Diagnosis of any chronic diseases such as diabetes, high blood pressure, arthritis, emphysema, or stroke.

• Unusual weight loss or gain in a short amount of time.

• Incontinence.

• Balance problems: How steady is the person while walking?

• Persistent fatigue or sleeplessness.

• Swollen feet or legs, or limping.

• Vision problems such as cataracts or use of vision aids.

• Hearing problems: Is there a need for a hearing aid? If there is one, is it being worn? 

• Dental problems including gum disease, halitosis and ill-fitting dentures. 

• Complaints of pain.

• List of health professionals being seen. 

 

Mental health

• Make note of these factors; a primary care doctor can help, but a geriatric psychiatrist or neurologist might be more helpful.

• Diagnosis of any psychiatric disorders such as depression, anxiety disorder or psychosis.

• Diagnosis of Alzheimer’s or other form of dementia. 

• Recent hospitalizations for any of these problems.

• Mood swings, including rage or hostility.

• Forgetfulness or wandering off.

• Sadness or loneliness.

• Decreased interest in reading, writing and communicating.

• Difficulty in maintaining friends.

• Decreased interest in life.

 

Medication use

• List all medicines taken, prescription or over-the-counter, with frequency and dosage.

• List all herbal remedies, supplements, traditional home remedies or vitamins being used.

• Is the person able to take medications as directed and avoid interactions?

• Are there any barriers to proper medicine use, such as forgetfulness, expense, poor understanding of purpose and results of use?

 

Daily living

• List special dietary needs and favorite foods.

• Describe ability to dress, bathe, get up from a chair, use the toilet, use the phone, climb stairs, get help in an emergency, shop, prepare meals, do housework and yard work, and drive safely.

 

Home and community safety

• Consider neighborhood safety. 

• Consider home safety: Are there throw rugs? A need for handrails in the bathroom? Does the residence have working smoke alarms?

• Is the person able to avoid telephone and door-to-door fraud?

• What level of maintenance do the yard and house require?

 

Support system 

• Know contact information for key family members, friends, neighbors and clergy.

• Does the person have visitors or is he or she able to visit friends and family?

• Does the person visit a senior center for activities?

• List membership in organizations and groups.

 

Appearance and hygiene
Factors to assess:

• Personal hygiene.

• Overall appearance.

• Oral care.Trimmed nails.

• Well showered and shaven.

• Combed hair.

• Clean clothes.

• Appropriately dressed for weather and occasion.

 

Finances
Factors to assess:

• Insurance coverage.

• Long-term care coverage.

• Total assets.

• Legal documents including trusts, living wills and durable powers of attorney.

• Is there an attorney who knows this person?    

 

Interests/lifestyles

• Hobbies.

• Reading preferences: Are glasses or larger-print books needed? Would books on tape be enjoyable?

• Favorite TV and radio programs.

• Exercise — gardening and walking count!

• Musical instruments played.

• Languages spoken, and is there a preferred language?

• Favorite conversation topics.

• Travel experience.

• Important life events.

• Religious/spiritual background.

• Accomplishments.

• Social activities.