Assess Your Needs
Mount Carmel Assessment
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Todays Date
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First & Last Name (Person of Contact) *
Phone Number *
First & Last Name (Patient in need of Care) *
Date of Birth (Patient in need of Care) *
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Gender
Clear selection
How quickly do you need to make a decision? *
Required
Senior in need of Care is currently at:
Im inquiring for my:
Best Describe Their Level of Needs:
Is the senior or their spouse a veteran?
Do they require injections?
Approx. Weight and Height of Senior
Biggest Challenges faced while making adequate care:
Clear selection
Please type in your MAXIMUM monthly budget (0-$10,000+)
Funding Options being currently used:
Daily Activity
Accomplishes Alone
Needs Some Help
Needs Much Help
Unsure
Bathing
Getting Dressed
Feeding Self
Eating a nutritious diet
Walking
Using the toilet
Getting out of bed or a chair
Taking medications
Competency
Good
Moderate
Poor
Unsure
Health
Mobility
Balance
Memory
Managing medications
Unique Care
Yes
No
Unsure
Needs an assistive device to get around (walker, wheelchair)?
Uses an electric scooter?
Has been diagnosed with Dementia or Alzheimer’s Disease?
At risk of wandering or exiting without the needed supervision?
Takes medications for mental health issues (Bi-Polar, Schizophrenia, Depression)?
Has severe vision impairment or is blind?
Has severe hearing impairment or is deaf?
Can’t control when they have a bowel movement?
Uses a feeding tube?
Has a colostomy or pouch to collect waste from the body?
Has a urinary catheter?
Is a smoker?
Needs oxygen therapy or uses a device to get oxygen?
Needs a ventilator?
Has a tracheotomy tube?
Has a bandaged wound someone else needs to take care of?
Bedridden or bed bound?
Insists on bringing a small pet?
Where did you hear about us?
Additional Information you would like to include?
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