Behavioral Level of Care Assessment

Let's create an overview of Comprehension, Capabilities, Mobility, Medical and Activities.

This assessment helps us to keep your loved one safely in their familiar surroundings to enjoy quality of life!

Please complete the form below and we will contact you as soon as possible.

 
Can Manage their Finances
1 (Not at all)
2
3
4
5 (All the time)
 
Is frequently confused
1 (Not at all)
2
3
4
5 (All the time)
 
Requires medication reminders
1 (Not at all)
2
3
4
5 (All the time)
 
Experiences frequent memory lapses
1 (Not at all)
2
3
4
5 (All the time)
 
Wanders
1 (Not at all)
2
3
4
5 (All the time)
 
Depends on others to plan his/her activities
1 (Not at all)
2
3
4
5 (All the time)
 
Needs repeated reminders to perform daily chores such as bathing or shaving
1 (Not at all)
2
3
4
5 (All the time)
 
Is often fearful
1 (Not at all)
2
3
4
5 (All the time)
 
Impaired Attention
1 (Not at all)
2
3
4
5 (All the time)
 
Impulsive Behavior
1 (Not at all)
2
3
4
5 (All the time)
 
Problem solving deficits
1 (Not at all)
2
3
4
5 (All the time)
 
Loss of awareness of disability
1 (Not at all)
2
3
4
5 (All the time)
 
Sporadic loss of conscious awareness
1 (Not at all)
2
3
4
5 (All the time)
 
Is capable of driving
1 (Not at all)
2
3
4
5 (All the time)
 
Has permanent disability
1 (Not at all)
2
3
4
5 (All the time)
 
Has impaired vision
1 (Not at all)
2
3
4
5 (All the time)
 
Has impaired hearing
1 (Not at all)
2
3
4
5 (All the time)
 
Has impaired speech/language skills
1 (Not at all)
2
3
4
5 (All the time)
 
Is acceptant to vision/hearing or speech/language skills loss
1 (Not at all)
2
3
4
5 (All the time)
 
Agrees he/she needs daily assistance
1 (Not at all)
2
3
4
5 (All the time)
 
Uses a walker
1 (Not at all)
2
3
4
5 (All the time)
 
Needs help moving from bed to wheelchair
1 (Not at all)
2
3
4
5 (All the time)
 
Is a couch potato
1 (Not at all)
2
3
4
5 (All the time)
 
Has loss of upper extremity motor control
1 (Not at all)
2
3
4
5 (All the time)
 
Has loss of lower extremity control
1 (Not at all)
2
3
4
5 (All the time)
 
Overall degree of disability
1 (Not at all)
2
3
4
5 (All the time)
 
Has been diagnosed with a type of dementia (such as alzheimer's disease)
1 (Not at all)
2
3
4
5 (All the time)
 
Is irritable
1 (Not at all)
2
3
4
5 (All the time)
 
Is sometimes aggressive
1 (Not at all)
2
3
4
5 (All the time)
 
Depression (secondary to dementia)
1 (Not at all)
2
3
4
5 (All the time)
 
Has type one diabetes
1 (Not at all)
2
3
4
5 (All the time)
 
Has type two diabetes
1 (Not at all)
2
3
4
5 (All the time)
 
Has controlled diet
1 (Not at all)
2
3
4
5 (All the time)
 
Takes oral diabetes medicine
1 (Not at all)
2
3
4
5 (All the time)
 
Takes insulin injections/pump
1 (Not at all)
2
3
4
5 (All the time)
 
Has been educated about their diabetes
Has no diabetes
1 (Not at all)
2
3
4
5 (All the time)
 
Complies with prescription treatment plan
1 (Not at all)
2
3
4
5 (All the time)
 
Has hypoglycemic episodes
1 (Not at all)
2
3
4
5 (All the time)
 
Requires aid during hypoglycemic episodes
1 (Not at all)
2
3
4
5 (All the time)
 
Condition
Condition improving
Condition Stable
Condition Worsening/deteriorating
 
Engages in regular exercise
1 (Not at all)
2
3
4
5 (All the time)
 
Frequently participates in social activities and hobbies
1 (Not at all)
2
3
4
5 (All the time)
 
Attends religious activities regularly
1 (Not at all)
2
3
4
5 (All the time)
 
Enjoys caring for his/her house
1 (Not at all)
2
3
4
5 (All the time)