Mobility: How would you describe their mobility?

Fully mobile and independent

Needs occasional assistance (e.g., using a cane or walker)

Requires frequent assistance (e.g., help with transfers)

Primarily uses a wheelchair

How would you describe their memory?

Sharp and independent

Occasionally forgetful (e.g., forgets names or appointments)

Frequently forgetful (e.g., forgets recent events, difficulty with routines)

Requires supervision for safety (e.g., wanders, forgets to turn off appliances)

Self-Care Abilities: How well can they perform daily activities (bathing, dressing, eating)?

Fully independent

Needs occasional assistance

Needs regular assistance

Requires full assistance

Social Engagement: How socially active are they?1

Very socially active (e.g., regular social events, clubs)

Somewhat socially active (e.g., occasional events or visits)

Prefers solitude, occasional visits

Limited social interaction, requires encouragement to engage

What type of care are you considering?

In-Home Care – Support while remaining at home

Assisted Living – Support in a residential care setting

I’m Not Sure – Help me determine the best option

Who is this quiz for?

Myself

Mom

Dad

common.other_option

Where do you want us to send the Assessment?

First Name

Last Name

Email *

Phone *

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