ONLINE ASSESSMENT FORM

Please take a few moments to fill out this form, so we can better get an understanding of your situation.

Your Name (first name is ‘ok’)
Prospective Resident's Name 
Prospective Resident's Age
Your email address:

CURRENT LIVING SITUATION (of prospective resident)

Presently at:  

How long at present location?  

Living:  

Ever lived at any other senior residence?    Yes No

LIVING ACTIVITIES    (Rate current status as best you know … ‘most of the time’)

1 = Independent   2 = Needs Assistance   3 = Totally Dependent    DNK = Do Not Know   
N/A = Not Applicable

Wake Up

Get Out of Bed    select Clothing   Get  Dressed

Ability to

Bathe Self    Wash own hair   Use Makeup

Shave Self   Brush Teeth   Feed Self   Toilet Self  

CURRENT ABILITIES (check each that applies to the best of your knowledge)

Ambulation (Walking)

Memory

Orientation

Communications

Bowel Control

Sleep Patterns

PERSONALITY / BEHAVIOR (check each that applies to the best of your knowledge)
 
1 = Occurs often   2= Occurs sometimes   3= Never occurs

Anxious/worried ‘Hears’ things Rummaging
Mood Swings Withdrawn/depressed Suspiciousness
Very fearful Crying/tearful Verbally Abusive
‘Sees’ things Pacing Physically Abusive
Overeating Resistant to touch Clinging
Do difficult behavior changes occur more often in the afternoon/evening? Yes No

Please let us know what are the most important issues for you and your loved one:

(check one that applies)

Immediate placement
Long term placement
Short term placement – respite and/or recovery
Placement in a family, home atmosphere
Home with lots of area to walk around
Activities
Skill and ‘touch’ of caregivers who will care for resident
Price of care
Price of care and length of care (total price over long period of time)
Placement close to where family and friends can visit
Experience of staff in dealing with ‘difficult to care for residents’
Record of  annual ‘Unannounced Visits’ to facility by Department of Social Services
What questions or information would you like to provide that we did not ask about?  

Do you want us to summarize the assessment for price and reply to you by email?  
  Yes No 

How did you hear About Us?  

Do you want to set a time to visit Lakeside Manor?   Yes No
If yes, please set a date and time and give us a phone number to call to RSVP your request.

Best date and time you can visit  
Phone Number   

Thank you for Inquiring about Lakeside Manor! We will respond within 1-2 business days