Questionnaire

Should Your Relative Live Alone?

It’s often difficult to know what service needs your relative may have when returning home from the hospital. This checklist may serve as a guide to evaluate if your older adult relative can safely continue to live alone.

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Safety needs

• Has you relative had accidents because of weakness,dizziness, or inability to get around
• Has use of a stove, oven or appliances become a safety problem of forgetfulness
• Are there hazardous conditions in his/her home,such as the bathroom and bedrom being on separate floors?
• Does your relative refuse to use wheelchair, walker or other assistive devices necessary for safety?
• Does your relative expressa desire to die, or seem to be depressed, apathetic, or without an interest in living?

Nutritional Needs

• Is There a demonstrated nutritional problem (weight loss,ilness, anemia, etc.)?
• Does your relative eat only inappropriate foods that will not supply nutritional needs?

Personal Needs

• Is your relative unwilling or unable to get to the toilet when necessary?
• Is your relative unable to change clothing or bed linens as necessary to remain clean and dry?

Needs e-mail Social

Medical Needs

• Does your relative forget to take necessary medications?
• Is it likely that your relative would take an inappropriate dose of medicine, purposely or accidentally?
• Is your relative unable to obtain help in case of need?

Social Needs

• Is your relative unable to handle money
• Does your relative get lost in familiar situations?
• Has your relative left home without destination?
• Does your relative often behave inappropriately?
• Does your relative have mental or emotional problems which might be a threat to self or others?

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INDIANA
Munster, IN
Phone: (219) 865 4775