Assessment Checklist
En español | If you’re doing an assessment on your own, use this list as a guide. Gently explore as many of these areas as you can to get a full picture of your loved one’s life.
Physical health
- Make note of these factors; you may need the help of your loved one’s doctor.
- Diagnosis of any chronic diseases such as diabetes, high blood pressure, arthritis, emphysema, or stroke.
- Unusual weight loss or gain in a short amount of time.
- Incontinence.
- Balance problems: How steady is the person while walking?
- Persistent fatigue or sleeplessness.
- Swollen feet or legs, or limping.
- Vision problems such as cataracts or use of vision aids.
- Hearing problems: Is there a need for a hearing aid? If there is one, is it being worn?
- Dental problems including gum disease, halitosis and ill-fitting dentures.
- Complaints of pain.
- List of health professionals being seen.
Mental health
- Make note of these factors; a primary care doctor can help, but a geriatric psychiatrist or neurologist might be more helpful.
- Diagnosis of any psychiatric disorders such as depression, anxiety disorder or psychosis.
- Diagnosis of Alzheimer’s or other form of dementia.
- Recent hospitalizations for any of these problems.
- Mood swings, including rage or hostility.
- Forgetfulness or wandering off.
- Sadness or loneliness.
- Decreased interest in reading, writing and communicating.
- Difficulty in maintaining friends.
- Decreased interest in life.
Medication use
- List all medicines taken, prescription or over-the-counter, with frequency and dosage.
- List all herbal remedies, supplements, traditional home remedies or vitamins being used.
- Is the person able to take medications as directed and avoid interactions?
- Are there any barriers to proper medicine use, such as forgetfulness, expense, poor understanding of purpose and results of use?
Daily living
- List special dietary needs and favorite foods.
- Describe ability to dress, bathe, get up from a chair, use the toilet, use the phone, climb stairs, get help in an emergency, shop, prepare meals, do housework and yard work, and drive safely.
Home and community safety
- Consider neighborhood safety.
- Consider home safety: Are there throw rugs? A need for handrails in the bathroom? Does the residence have working smoke alarms?
- Is the person able to avoid telephone and door-to-door fraud?
- What level of maintenance do the yard and house require?
Support system
- Know contact information for key family members, friends, neighbors and clergy.
- Does the person have visitors or is he or she able to visit friends and family?
- Is he able to visit a senior center?
- List membership in organizations and groups.
Appearance and hygiene
Factors to assess:
- Personal hygiene.
- Overall appearance.
- Oral care.Trimmed nails.
- Well showered and shaven.
- Combed hair.
- Clean clothes.
- Appropriately dressed for weather and occasion.
Finances
Factors to assess:
- Insurance coverage.
- Long-term care coverage.
- Total assets.
- Legal documents including trusts, living wills and durable powers of attorney.
- Is there an attorney who knows this person?
Interests/lifestyles
- Hobbies.
- Reading preferences: Are glasses or larger-print books needed? Would books on tape be enjoyable?
- Favorite TV and radio programs.
- Exercise — gardening and walking count!
- Musical instruments played.
- Languages spoken, and is there a preferred language?
- Favorite conversation topics.
- Travel experience.
- Important life events.
- Religious/spiritual background.
- Accomplishments.
- Social activities.
