| Is it important to the person to continue living independently in their own home? |
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| Is s/he alone for many hours on most days? |
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| Has s/he fallen or been anxious about falling in the past year? |
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| Has s/he been hospitalized, or been to the emergency room, in the past year? |
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| Does s/he take several daily medications? |
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| Has s/he lost weight without trying in the last month? (10 or more pounds) |
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| Does s/he require assistance with one or more of the following activities: bathing, toileting, dressing, meal preparation, getting up from a chair or bed? |
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| Does s/he forget to turn off the stove? |
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| Is bathing infrequent? (fewer than 3 times per week) |
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| Is there bladder or bowel incontinence? |
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| Is there bad body and/or mouth odor? |
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| Is appearance unusually sloppy? |
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| Does s/he wear the same clothes for several days and nights at a stretch? |
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| Does laundry accumulate and pile up? |
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| Do bed linens remain unchanged for weeks? |
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| Does s/he have difficulty doing her/his own shopping? |
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| Does s/he have difficulty preparing her/his own meals? |
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| Does s/he forget to eat? |
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| Is the home often dirty and cluttered? |
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| Is there an odor to the house and/or bed? |
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| Are pets neglected? (lack of food and water daily, litter box dirty, dog not walked….) |
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| Does s/he often forget where s/he is going or what s/he is doing? |
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| Does s/he often forget what s/he is saying or lose track of what others are saying? |
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| Does s/he often forget to pay bills? |
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| Does s/he get confused, become angry and act out? |
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| Has s/he attempted to harm self or others? |
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| Would having a regular, trained care provider to help with daily activities give you peace of mind? |
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