I. I would like assistance for my: Mother Father Both Other (specify)
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1 Senior Care Solutions Form 2 Page 1 of 7 Your FAMILY QUESTIONNAIRE Date I. I would like assistance for my: Mother Father Both Other (specify) PLEASE NOTE: IF THE PERSON NEEDING HELP LIVES WITH A SPOUSE/CAREGIVER, PLEASE INCLUDE INFORMATION ON BOTH PARTIES AS MUCH AS POSSIBLE. His/Her/Their (s) City State Zip Phone # Birthdate / / Birthplace S.S. #s: XXX-XX- Ethnic, racial or cultural background Education Religion Active religiously? If so, where Marital Status (circle one): Single Married Separated Divorced Widowed Date of divorce or widowhood (if applicable) Describe impact of this loss on relative Insurance Information Medicare A B Medicare #(s) Medigap Insurance: Provider Medigap Policy # Does policy cover mental health benefits? Yes No HMO HMO Policy # Phone Do you have long-term care insurance? Family Information ( ) Relatives of person needing assistance
2 Page 2 of 7 Who will take ongoing responsibility for talking with Care Manager? Who will be responsible for payment of services provided by Senior Care Solutions? List friends, neighbors and relatives who help your relative(s): Specifically, how does s/he help? Phone Specifically, how does s/he help? Phone Specifically, how does s/he help? Phone List lawyer, accountant, significant others: Lawyer Power of Atty. (Finances) Power of Atty. (Healthcare) Significant other(s) Phone #: How would you rate the present support system? Excellent Good Fair Poor Any recent problems with this support system? Which of these people would you or your relative(s) call in an emergency? List in-home help, phone, and degree of satisfaction Phone/agency Circle degree of satisfaction Circle rate of Frequency House cleaning High Medium Low Daily Weekly Monthly Home aid(s) High Medium Low Daily Weekly Monthly Other High Medium Low Daily Weekly Monthly
3 Page 3 of 7 Describe type of living environment (circle appropriate descriptions) Rent Own Apartment House Condominium Adequacy of home environment (circle appropriate description) Excellent Fair Poor IV. Medical Information List significant doctors and other health specialists the relative(s) sees now or has seen recently. Phone For what problem Describe the most significant health problems, treatments, and medications: Problem Treatment Medication Date of last checkup Known allergies Recent hospitalization? Y N Describe reason and outcome Describe relative s reactions to his/her own medical support system; describe your reactions to this system also.
4 Page 4 of 7 V. Self-care and Daily Living Information Check problem areas in daily living: Driving Bathing Decision making Using other transportation Dressing Toileting Using telephone Managing money Transfer Preparing light meal Taking medications Walking Cleaning/laundry House maintenance Other Eating Grocery shopping Other Please explain: Which of the following are problems/risks? Please check Suicide Drinking Sleeping Wandering Setting Fire Other Who buys groceries, prepares meals? State if there are any nutritional concerns? Summarize present capacity for self-care: Memory, Orientation and Judgment If any memory problems exist, how disabling are they? Consider, does your relative recognize you, the time, his/her location? Does s/he make sense most of the time? Has there been any recent long-term memory loss? Would you rate memory problems as mild, moderate, or severe? Is there a medical diagnosis and current treatment? Emotional Health
5 Page 5 of 7 Describe basic personality. How does your relative cope? Do you see him/her as dependent, anxious, withdrawn, content, lonely, or other? Are you concerned about any recent changes in behavior or sense of well-being? If so describe. (What hints have you received lately?) Does (do) your relative(s) share your same concerns or worries as stated above? Y N Any history of emotional problems? Y N Past or present treatment? Y N Has relative experienced recent losses of any kind (health, loved ones, job, etc.)? Describe impact. Social Life What is the extent of your relative s social life, interests? Do you feel it is satisfactory? Any significant changes? Does your relative feel satisfied? Please explain.
6 Page 6 of 7 Work and Retirement What was your relative s occupation or profession? Date of retirement How was the adjustment to retirement? Please describe. VI. Other Pertinent Information Hospital Preference Trust Will D.N.R. Order Lifecare Living Will Funeral Arrangements Cemetery Plot Are there financial problems? Please describe. Form 2
7 Page 7of 7 VII. Summary Now that you have had time to outline this information, please tell us what your major concerns are and specifically what type of assistance you seek. In your opinion, in what areas of life would your relative be accepting of help (i.e. help with personal chores, companionship, memory, personal problems)? Give this some thought, as this is key to the social worker s plan for a successful approach to your relative.
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