Is your loved one wearing clothing that is dirty or has food stains?
Y N
Does your loved one wear his/her night clothes during the day?
Y N
Does your loved one wear the same outfit day after day?
Y N
Is it apparent your loved one is not showering or bathing?
Y N
Does your loved one fail to comb/style their hair or brush their teeth?
Y N
Is your loved one losing weight?
Y N
Is there unusual tearing or bruising of the skin that may indicate a fall?
Y N
Does your loved one fail to recognize you or know your name?
Y N
Does your loved one fail to speak normally or have trouble communicating?
Y N
Are there signs of confusion such as not knowing the date, where he/she is, or, the season of the year?
Y N
Has your loved one withdrawn socially or is he/she less communicative?
Y N
Are there foul smells coming from the refrigerator and cupboards?
Y N
Are the cupboards void of nutritious food?
Y N
Is the home cluttered and does it have newspapers and mail accumulated?
Y N
Are you finding expired medications or medications that are not being taken?
Y N
Has your loved one fallen recently?
Y N
Submit
