Needs Assessment

Please complete this form to assist us in helping you locate the appropriate facility in your elderly family member's city or nearby area. Complete only the items that apply to your family member. All personal information you provide is held in the strictest confidence by A Granddaughter's Promise and is not shared with any other parties.

Your Loved One's Name
Title
First Last Suffix
Your Loved One's Age
Is Your Loved One a Veteran? Yes No
Please check one.
Physical Information
Your Loved One's Height
Your Loved One's Weight
Ambulation Level Walks Unassisted Uses a Cane Uses a Walker Uses a Wheelchair
Please check all that apply.
Wheelchair Transfer Assistance Needs No Help Needs Some Help Needs Total Assistance
Needs Help With Activities of Daily Living Bathing Dressing Hair Care and Shaving Eating Toileting
Please check all that apply.
Incontinent Bladder Bowel Wears Diapers
Please check all that apply.
Vision Fair to Good Vision Poor Vision Legally Blind
Please check one.
Hearing Fair to Good hearing Poor Hearing Deaf
Please check one.
Sleep Habits Sleeps Through Night Up Once or Twice Up Three or More Times
Please check one.
Medical Information
Cognitive Impairment Diagnosed with Alzheimer's disease Diagnosed with dementia Confused Short Term memory loss Wanders at night Wanders outside Agitated or Combative
Please check all that apply.
Special Medical Needs Oxygen Urinary Catheter Colostomy
Please check all that apply.
Other Special Medical Needs
Diabetic Controlled with medications Insulin injections Special diet N/A
Please check all that apply.
Any additional information about your Loved One:
Responsible Party Information
Name
Title
First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Relationship to Loved One
Primary Phone (###) ###-####
Other Phone (###) ###-####
E-mail Address
Facility Preferences
Facility Type Assisted Living Facility Small Residential Care Home Retirement Community Nursing Home
Please check all that you would consider.
Room Type One Bedroom Two Bedroom Studio Private Room Semi-Private Room
Please check all that apply.
Estimated move-in date / MM / DD YYYY
Monthly Budget
Additional Information Regarding Your Search

Needs Assessment

Needs Assessment

Physical Information

Medical Information

Responsible Party Information

Facility Preferences