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Is There A Need?
The following questions are designed to assist you in identifying the need for home care and the level of care necessary.
1. Please choose the best answer that describes the person needing care:
General Health
Frail Poor Fair Good  
Does the person needing help have a physical disability?
  Yes No    
What is the person's age?
86 or older 85-71 70-60 59 or younger
Please select the statement that best describes the person's current living arrangement.
  Alone without needed help   Alone, has help   With someone who can't help   With someone who can help   Self-sufficient
Please select the statement that best describes the person's current mental condition.
  Diagnosis of Alzheimer's or other mental dysfunction   Frequent confusion and/or disorientation   Sometimes confused and forgetful   No Problem

2. How difficult is it for the individual needing care to perform the following activities of daily life:
  Very Moderately No Difficulty
Personal care and Grooming        
Ability to get around in the house        
Managing the household tasks        
Meal preparation and nutrition        
Getting out of the home to shop, etc.        
Socialize with others        
Medication compliance        
         

3. Does the person rely on others for these tasks?
  Yes No    

4. Has there been deterioration in the physical or mental health of the individual or in the ability to manage daily activities within the past 6 months?
  Yes No    

5. Does the need for care create stress for you or other family members?
  Yes No    

6. Is your concern magnified by any of the following (check all that apply)
  Family tension
  Lack of knowledge
  Inability to provide care due to personal commitments, distance, etc.
  Feeling of being overwhelmed

7. Is the person in need of care able to handle an emergency in the home?
  Yes No    

8. If something doesn't change, will it be difficult or impossible for this person to stay at home?
  Yes No    

9. Are you worried about this individual?
  Yes No    
   
 
For 50 years Visiting Homemaker Service has been a trusted home care provider of homemaker, personal care, companion, housekeeping, and nursing services. The VHS staff of registered nurses, social workers, certified home health aides and supervised home care aides average more than ten years of service.

Visiting Homemaker Service of Hudson County
586 Newark Avenue, Jersey City, New Jersey 07306
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