Are you concerned for a loved one and their ability to remain safely in their home? Completing this simple assessment will help you identify potential risks and threats to their independence, and will give you a starting point for finding options to address those needs.

Physical Health

• Has your loved one been diagnosed with any chronic illnesses or diseases?
• Has she been hospitalized recently?
• Has she fallen or had accidents because of weakness, dizziness, or inability to get around?
• Has there been a recent change in weight – especially unexplained weight loss?

 Mental Health

• Has your loved one been diagnosed with Alzheimer’s disease or another form of dementia
  or memory loss?
• Has he been diagnosed with a mental health disorder such as depression, anxiety, or psychosis?
• Is he showing signs of confusion, disorientation, or isolation?
  What about mood swings or forgetfulness? Sadness or loneliness?

Medication Use

• Is your loved one taking multiple medications – either prescription, over-the-counter, or supplements?
• Does she have trouble taking her medications as directed, i.e. the right amount at the right time
  and with the proper foods or liquids?
• Does she ever forget to take her medicines or skip dosages to save money?

Daily Living Skills

• Does your loved one have difficulty bathing or dressing?
• Does he have trouble getting up from a chair, walking, or navigating stairs?
• Does he have trouble making it to the bathroom in time?
• Does he have trouble using the phone or getting help in case of an emergency?
•  Does he need help shopping, preparing meals, doing housework or yard work?
• Has he ever forgotten to turn off the stove, oven, or water?
• Is his home in disarray? Does it need cleaning? Is this a change?
• Do you worry about his driving abilities or believe he shouldn’t be driving?
  Has he had any accidents, near misses, or tickets recently?

Home and Community Safety

• Are you concerned about the safety of your loved one’s neighborhood?
• Does her home have safety issues, e.g., throw rugs, smoke alarms that don’t work or
  can’t be heard, steps that can’t be easily navigated, wiring problems, or inadequate
  heating or air conditioning?
• Does she refuse to use a wheelchair, walker, hearing aids, or other assistive devices
  necessary for safety?
• Is she vulnerable to telephone, mail, or door-to-door solicitations or fraud?
• Is she unable to maintain the house or keep up with needed repairs?
• Has she ever gotten lost or been unable to find her way home?

Socialization/Support Systems/Interests/Lifestyles

• Has your loved one quit having frequent contact with family and friends?
• Does he lack family or friends nearby to call on for help?
• Is he reluctant to leave the house?
  Has he lost touch with church, work, or social groups that he previously enjoyed?
• Does he watch too much TV or sleep too much during the day?
• Has he lost interest in his favorite hobbies or pastimes, church or senior center activities?

These questions are phrased in such a way that “Yes” answers suggest a possible area of concern.