Housing Needs Assessment

Directions: Use this survey to identify what you are looking for in a nursing home. This document will help when meeting with facility staff. For each category, check all that apply.

Reason for housing

Individual can no longer take care of him/herself
Individual requires more care than family or friends can provide
Individual has medical needs requiring supervision
Physician recommended
Discharged from hospital but requires temporary skilled care before returning home

Level of care needed

Supervision only
Assistance with daily living activities (example: bathing, dressing, incontinence, eating, etc.)
Therapy (example: physical, occupational)
24-hour nursing
Intensive nursing
Other (please describe):

Medical conditions

Alzheimer's disease
Cancer
Cardiovascular disease
Chronic pain
Dementia
Developmentally disabled
Head trauma
Hematologic condition
Mental disease
Neurological disease
Orthopedic/skeletal problems
Pulmonary disease
Para/quadriplegic
Stroke
Trauma
Wound
Other (please describe):

Physician-recommended therapies

Physical
Occupational
Speech
Respiratory
Reality
Other (please describe):

Equipment and Supplies

Intravenous drugs
Medical supplies
Prescription drugs
Prosthetics
Oxygen
Special bed
Ventilator
Wheel chair
Other (please describe):

Routine medical specialists needed

Dentist
Dietician
Opthamologist
Physician
Podiatrist
Other (please describe):

Financial resources available

HMO or managed care
Medicaid
Medicare
Private long-term care insurance
Private pay
Veteran?s benefits
Other (please describe):

Transportation

Facility provided
Family provided
Public transportation

Social activities preferred

Arts and crafts
Cards and games
Interaction with others
Movies
Outdoor activities
Pet therapy
Prayer groups
Reading
Social events
Television
Other (please describe):
Attend religious services
Religious Affiliation:

Special Needs

Language (other than English):
Medically prescribed diet
Asian vegetarian
Diabetic
Gluten free
Hindu
Kosher
Lacto-ovo vegetarian
Low calorie
Low protein
Low purine
Low sodium
Low-fat/low cholesterol
Muslim
Obento Japanese
Vegan
Food allergies:

Facility preferences

Private room
Semi-private room
Small facility (less than 25 beds)
Medium facility (26 to 100 beds)
Large facility (over 100 beds)

Activities where assistance is needed

Bathing
Continence
Dressing
Eating
Housekeeping
Laundry
Managing finances
Meal preparation
Mobility
Personal care
Shopping
Taking medication
Telephoning
Toileting
Transportation
Other (please describe):

Legal

Potential resident has a will
Potential resident has durable power of attorney in place
Potential resident has any advanced directives:

Survey completed for:

Name:

Physician Name:

Age:

Contact Information:

Name:

Address:

City:

State/Zip:

Telephone:

Email:

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