Are You Prepared? A Senior Care Preparedness Assessment
Your Senior Care Checkpoint
Introduction:
Caring for an aging loved one is a unique and demanding journey. Just like understanding your personality or communication style can help you navigate relationships, understanding your current preparedness and stress level can help you determine the level of support you need. This assessment will help you identify your strengths and potential areas where professional guidance could make a significant difference. It's not a test, but a tool for self-reflection. Before we get started, please provide your contact information.
Name
*
First Name
Last Name
Email
*
theagingparentsolution.com
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Section 1: Understanding Your Situation
1. How would you describe your current understanding of your parent's/loved one's overall health (physical, cognitive, emotional)?
*
Excellent
Good
Fair
Poor
I'm unsure
2. Considering your parent's/loved one's overall health, can you elaborate on any specific conditions or diagnoses they are currently managing? (e.g., heart disease, dementia, arthritis, diabetes). How stable are these conditions currently?
*
Very Stable
Stable
Somewhat Stable
Not Stable At All
3. Thinking about the time you dedicate to caregiving, can you break down the types of activities this involves? Which of these activities takes up the most of your time:
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Personal Care
Companionship
Managing Finances
Transportation
Emotional Support
4. How many hours per week, on average, are you actively involved in providing care or managing care for your loved one?
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0-5 Hours
6-15 Hours
16-30 Hours
31-40 Hours
Over 40 Hours
5. When it comes to support, are there specific types of support that would be most helpful to you right now that you are not currently receiving?
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Respite Care
Emotional Support
Help With Specific Tasks
Financial Assistance
6. How would you rate the level of support you receive from other family members or friends in caregiving?
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Excellent – I have a strong and reliable support system.
Good – I have some support, but it's not always consistent.
Fair – Support is limited or infrequent.
Poor – I have very little support.
No support available.
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Section 2: Assessing Your Preparedness
7. Are the following documents readily accessible and up-to-date? (Check all that apply)
*
Medical Records
List of Medications
Insurance Information
Advance Directives (Living Will, Healthcare Proxy)
Financial Power of Attorney
Long Term Care Insurance
Asset Information
8. Have you discussed the contents of these documents with your loved one and other relevant family members?
*
Yes
No
9. Have you met with an Elder Law Attorney or an Estate Planner?
*
Yes
No
10. How confident are you in your ability to manage the following aspects of your loved one's care? (Rate each on a scale of 1-5, where 1 is "Not Confident" and 5 is "Very Confident")
Scheduling and Attending Medical Appointments
Not Confident
1
2
3
4
Very Confident
5
1 is Not Confident, 5 is Very Confident
Communicating with Healthcare Providers
Not Confident
1
2
3
4
Very Confident
5
1 is Not Confident, 5 is Very Confident
Managing Medications
Not Confident
1
2
3
4
Very Confident
5
1 is Not Confident, 5 is Very Confident
Handling Financial Matters Related to Care
Not Confident
1
2
3
4
Very Confident
5
1 is Not Confident, 5 is Very Confident
Addressing Emotional and Behavioral Changes
Not Confident
1
2
3
4
Very Confident
5
1 is Not Confident, 5 is Very Confident
11. Have you explored the following long-term care options? (Check all that apply)
*
Home Care Services
Adult Day Care Programs
Assisted Living Communities
Skilled Nursing Facilities
Hospice Care
I Have Not Explored Any Options
12.Have you visited these communities and/or spoken to someone there?
*
Yes
No
13. Do you understand how Medicare and Medicaid coverage works and available services provided through each?
*
Yes
No
14. Is your loved one eligible for Veterans Benefits and if so do you know how to apply?
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Yes
No
15. Does your loved one have a Long Term Care Insurance Policy? And if so do you know what it covers in regards to care and services?
*
Yes
No
16. Have you discussed with your family and loved one the care options and which ones you can afford?
*
Yes
No
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Section 3: Evaluating Your Stress and Coping
17. "How often do you experience the following feelings in relation to your caregiving responsibilities?" (Rate each on a scale of 1-5, where 1 is "Very Frequently" and 5 is "Rarely")
Feeling Overwhelmed
Very Frequently
1
2
3
4
Rarely
5
1 is Very Frequently, 5 is Rarely
Feeling Stressed or Anxious
Very Frequently
1
2
3
4
Rarely
5
1 is Very Frequently, 5 is Rarely
Feeling Tired or Exhausted
Very Frequently
1
2
3
4
Rarely
5
1 is Very Frequently, 5 is Rarely
Feeling Guilty or Resentful
Very Frequently
1
2
3
4
Rarely
5
1 is Very Frequently, 5 is Rarely
Feeling Socially Isolated
Very Frequently
1
2
3
4
Rarely
5
1 is Very Frequently, 5 is Rarely
18. How do you feel about the current level of care you are providing?
*
Good
Unsure
Bad
19. Are you able to rely on others for help with caregiving tasks or emotional support?
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Yes
Sometimes
No
20. How often do you engage in self-care activities (e.g., exercise, hobbies, spending time with friends)?
*
Daily
A Few Times a Week
Occasionally
Rarely
Never
21. Are you able to maintain a healthy work-life balance?
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Yes
Sometimes
No
22. How would you rate your overall stress level related to caregiving?
*
Low
Moderate
High
Very High
23. Is this stress having a negative impact on your life?
*
Yes
No
24. Are you experiencing any physical symptoms, such as headaches, fatigue, or changes in sleep or appetite?
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Yes
No
25. Have you noticed any health problems that you think might be related to the stress of caregiving?
*
Yes
No
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