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Care Survey

Care Survey

It may be time to consider in-home living assistance for your loved one!  Our brief Care Survey can help you better understand your loved one’s needs of support.  Answer with a “yes” or a “no” to the questions you see below.  An email will be sent to you that shows your results. We will view your answers and personally email or call you (depending on your requested form of communication) to discuss your options.  If we don’t think you require in-home services, we’ll tell you! We will always respond to your survey inquiry. Thank you for trusting FamilyCARES.

Care Survey

1. Is your loved one losing weight?
2. Does your loved one wear his/her evening clothes during the day time?
3. Does your loved one fail to speak normally or have a difficult time communicating sometimes?
4. Does your loved one care less about their appearance lately? Examples: Failing to brush his/her teeth, washing his/her face & hands, or combing his/her hair?
5. Does your loved one exhibit signs of confusion? Examples: Forgetting the year, date, time, or season?
6. Have you noticed that your loved one has become socially withdrawn or has been communicating less with family and/or friends?
7. Does your loved one sometimes wear clothing that is dirty or has been stained with food?
8. Does your loved one wear the same clothing two days in a row?
9. Have you noticed unusual tearing or bruising of the skin that may indicate your loved one fell?
10. Does your loved one forget your name or fail to recognize you sometimes?
11. Have you noticed foul smells coming from your loved one's refrigerator or food cupboards?
12. Have you noticed an increase of clutter in your loved one's home? Examples: piling up of mail, newspapers, trash.
13. Have you noticed that your loved one is not taking their medications or you have found expired medications?
14. Is there a lack of nutritious food in your loved one's home?
15. Have you noticed that your loved one is not bathing/showering as much as they should?
16. Has your loved one said to you that they were scared, lonely, depressed, or sad recently?
Please submit your survey after filling out the necessary contact information.

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