|
Never |
Occasionally |
Often |
All The Time |
Elder person falls |
|
|
|
|
Visit to the ER |
|
|
|
|
Becomes Confused |
|
|
|
|
Trouble dressing self |
|
|
|
|
Needs help toileting |
|
|
|
|
Unpaid Bills |
|
|
|
|
Misses taking medications/missed meds |
|
|
|
|
Misses meals or decreased appetite |
|
|
|
|
Complains of bowel bladder trouble |
|
|
|
|
Unsteady gait |
|
|
|
|
Trouble with grooming/personal hygiene |
|
|
|
|
Wears same clothes for more than 2 days |
|
|
|
|
Weight loss or gain, fluctuation |
|
|
|
|
Home in disarray |
|
|
|
|
Misses Appointments |
|
|
|
|
Loss of interest in social activities |
|
|
|
|
Paranoia or suspicion |
|
|
|
|
Inappropriate behavior |
|
|
|
|
| |
|
|
|
|
Any of these marked occasionally should not be ignored, please contact your health care professional |
