Aging In Place

What is the individual's current living situation and are there any accessibility challenges within the home?

Does the individual have a support system of family, friends, or caregivers nearby?

Can the individual manage daily tasks such as cooking, cleaning, and personal hygiene independently?

How does the individual manage their medications, and are there any known health conditions that could impact their independence?

Are there any financial concerns regarding home modifications or in-home care services?

What are the individual's social and emotional well-being needs, and are they being met?

Are there any safety concerns or risks present in the home environment?

How is the individual's mobility, including walking, climbing stairs, and getting in and out of a chair?

Has there been any recent change in cognitive function, such as memory loss or difficulty with
decision-making?

Full Name of Client

Date of Birth

Current Address

Phone Number

Email Address

Preferred Language

Marital Status

Spouse's Name (if applicable)

Yes No

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