HOME HEALTH CARE ASSESSMENT

Understand the risk factors for your loved one’s condition.

Can Home Health Help Your Loved One?

If you’re an adult caring for your mom, dad or other family member with health care challenges, you’re not alone.

If you’re an adult caring for your mom, dad or other family member with health care challenges, you’re not alone. More than a third of Americans find themselves in the same position. It can be overwhelming for the entire family – especially if you don’t know where to turn for answers and support.

QUIZ-hand

This questionnaire will help you understand the risk factors for your loved one’s condition and if home health care can help. You’ll also receive a personalized report you can print or email so you can reference it later.

Has your mom, dad or loved one been diagnosed with any of these conditions?

Heart failure or other heart conditionStrokeDiabetesCOPD or other respiratory conditionAlzheimer’s/Dementia/ConfusionCancerOtherNone


Have they experienced any of the following in the past 3 months?

Serious illness (pneumonia, infection, flu)Joint replacement or surgery (knee, hip, shoulder, etc.)Falls, dizziness or loss of balanceTrouble eating or swallowingDepressionAmputationNone


Have they been diagnosed with a terminal condition and a life expectancy of six months or less?

YesNo


Has their doctor prescribed any of the following medications or treatments?

Coumadin/Warfarin (anti-clotting/blood thinner)Insulin or oral diabetic medicationPain MedicationIV MedicationDialysisOxygenOtherNone


Does your loved one have trouble keeping track of which medications they’re supposed to take, or have they accidentally taken the wrong medication or dose?

Frequently - Several times a monthRegularly - At least once a monthSometimes - A few times a yearRarely - Once a year or lessDon't know


Do they have difficulty performing any of the following activities?

BathingGetting dressedPreparing foodUsing the restroomGrocery shoppingDrivingNone


How often do they visit or call the doctor to deal with symptoms of their condition or side-effects from medication?

Frequently – Several times a monthRegularly – At least once a monthSometimes – A few times a yearRarely – Once a year or lessDon't know


How difficult is it for your loved one to move around and leave the house? Please select the option that best describes their current situation?


Their condition makes it very difficult or impossible to even leave bed.Leaving home requires a taxing effort that exhausts them. They leave home infrequently and briefly because of the difficulty.They use a walker, wheelchair, or require another person’s help to leave home.They have some difficulty leaving home, but not enough to stop them from going somewhere.They have no difficulty leaving home.


How can we contact you?

Your Name

Your Email

Phone Number


What are your health care needs?

Please select one of the health areas below to learn more details about that specific condition and how Cavalier can help.

Balance & Fall Prevention

Cardiopulmonary Disease

Parkinson’s and Neurological Disorders

Wound Healing and Lymphedema Treatment

Orthopaedic Rehab

Chronic Disease Management