Caregiver Assessment Questionnaire


  1. Has someone close to you fallen recently?
    Yes     No
  2. Are you concerned about the risk of a loved one falling?
    Yes     No
  3. Do you regularly need to remind an aging family member to bathe, eat, dress or take medications?
    Yes     No
  4. Is your loved one experiencing memory loss or forgetfulness?
    Yes     No
  5. Does a family member’s chronic illness require constant monitoring?
    Yes     No
  6. Has a loved one recently needed to visit the emergency room?
    Yes     No
  7. Has someone you provide care for been hospitalized in past three months?
    Yes     No
  8. Would professional assistance help make your new caregiving responsibility more manageable?
    Yes     No
  9. Do you need immediate assistance in giving your loved one the care that he or she requires?
    Yes     No
  10. Does your loved one currently require occupational therapy?
    Yes     No
  11. Does your loved one currently require physical therapy?
    Yes     No

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