This simple questionnaire has been prepared to assist you in determining whether your loved is ready for a special care program:
Please answer the following questions as honestly as you can: Does the person I am concerned about:
| Require assistance with dressing |
|
Yes No |
| Require assistance with showering |
|
Yes No |
| Forget to change his/her clothing |
|
Yes No |
| Forget to eat or requires help eating |
|
Yes No |
| Forget to take medications |
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Yes No |
| Wander outside and is unable to find his/her way back home |
|
Yes No |
| Have difficulty knowing correct time, date and season |
|
Yes No |
| Leave kitchen appliances on |
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Yes No |
| Withdraw from most or all social activities |
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Yes No |
| Have trouble remembering things that just happened |
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Yes No |
| Go to great lengths to cover up or hide deficits |
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Yes No |
| Believe that everyday items have been stolen. |
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Yes No |
| Appear frustrated and/or depressed over his/her inability to manage routine tasks |
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Yes No |
| Have family or friends become concerned or frustrated by the person's loss of ability to care for one's self?
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Yes No |
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If the answer is yes to at least four questions, it may be time to consider the Legacy Program at Woodbridge. Please call Harriet Flashenberg, LSW at
978-532-4411 for more information. |
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