Family Questionnaire

 

How will I know when my family member needs help?

 

1. Does your family member miss meals?

yes    no   maybe

Due to forgetfulness? yes    no   maybe

Has difficulty using hands/arms? yes    no   maybe

Has a swallowing problem? yes    no   maybe

 

2. Is your family member unable to evacuate home in case of an emergency?

yes    no   maybe

Due to limited physical capability? yes    no   maybe

 Due to mental capability? yes    no   maybe 

 

3. Is your family member unable to get in and out of a chair and/or bed alone?

yes    no   maybe

Due to limited physical capability? yes    no   maybe

Due to limited mental capability? yes    no   maybe 

 

4. Is your family member unable to use the commode alone?

yes    no   maybe

Due to limited physical capability? yes    no   maybe

Due to limited mental capability? yes    no   maybe

 

5. Is your family member unable to groom hair and self?

yes    no   maybe

Due to limited physical capability? yes    no   maybe

Due to limited mental capability? yes    no   maybe

 

Scoring Interpretation:

  • A "yes" answer indicates your family member could benefit from some assistance with their
    Active Daily Living (ADLs) for a few hours, two or more days per week.
  • Two to four "yes" answers indicate a definite need for assistance with their ADLs on a
    daily basis for a minimum of four hours per visit.
  • Five or more "yes" answers indicate a definite need for daily assistance, eight to 24 hours
    per day to ensure the individual's safety and well being.
  • "Unsure" answers indicate a need to monitor the suggested area for one week to determine
    if a "yes" or "no" answer would be appropriate and why.

For additional information and assistance, please contact Share the Care Network or
call (323) 280-3586.