ARE SERVICES NEEDED?

Warning Signs that Assistance May be Needed

The following questions assist families in determining whether help is needed. Any one of the behaviors listed may or may not indicate that an action should be taken and that your family member's physician should be kept informed of physical, psychological, and behavior changes.

If a great number of these items are checked yes, the services of a home services worker may be needed to protect the health and safety of your family member in their residence.

Safety Needs
Yes	No
[ ]	[ ]	Had physical problems such as burns or injury marks resulting from general weakness, forgetfulness, or possible misuse of alcohol or prescribed medicines?
[ ]	[ ]	Exhibited forgetfulness resulting in unopened mail, piling up of newspapers, not taking their medications, or missing appointments?
[ ]	[ ]	Neglected their home so it is not as clean or sanitary as it used to be?
[ ]	[ ]	Are their hazardous conditions around the house such as gas stoves, difficult to use bathtubs or toilets, or frequent use of stairs?
[ ]	[ ]	Physically unable to obtain help in case of need?
Nutritional Needs
Yes	No
[ ]	[ ]	Changed eating habits within the last year resulting in weight loss or decreased appetite?
[ ]	[ ]	Exhibited signs of missing meals and having food spoil in the refrigerator?
[ ]	[ ]	Frequently consuming foods with high sodium content and other low nutritional value snacks?
Personal Needs
Yes	No
[ ]	[ ]	Unwilling or unable to get to the toilet when needed?
[ ]	[ ]	Neglects personal hygiene resulting in wearing dirty clothes, body odor, bad breath, neglected nails and teeth, or sores on the skin?
Social Needs
Yes	No
[ ]	[ ]	Exhibited inappropriate behavior by being unusually loud or quiet, paranoid, agitated, and making phone calls at all hours?
[ ]	[ ]	Changed relationship patterns such that friends and neighbors have expressed concerns?
[ ]	[ ]	Decreased or stopped participating in activities that were previously important to them such as bridge or a book club, dining with friends, or attending religious services?
[ ]	[ ]	Becomes disoriented in familiar surroundings or “forgets” what they wanted to do?
Financial Needs
Yes	No
[ ]	[ ]	Mishandled finances such as not paying bills, losing money, paying bills twice or more, or hiding money?
[ ]	[ ]	Made unusual purchases such as buying more than one magazine subscription for the same magazine, entering an unusual amount of contests, increased usage and purchasing from television advertisements?