FORMS, CHECKLISTS OR TIPS
Some of these checklists have been developed by The Consumer Consortium on
Assisted Living (CCAL), a national, nonprofit organization dedicated to representing the needs of consumers in assisted
living facilities and educating consumers, professionals, and the general public about assisted living issues.
Where you see WORD DOC, click on it for document
inWORD format. The rest are forms or checklist located on the site it is linked to. |
Keep track of questions asked doctors, answers etc.
Assisted Living: Quality Of Life
A checklist of questions dealing with socializing, meals, safety, and other issues to consider
when you and your loved one visit an assisted living facility.
A checklist of personal and health care questions to ask when you and your loved one visit
an assisted living facility.
Better Family Communications
The better family members can communicate with each other, the better they can deal with hard times and difficult decisions.
Caregiving Decision Questionaire
A brief list of questions to help you set prioities and solve caregiving problems.
Use copies of this form to monitor daily changes and help with communication among care providers working in shifts.
Daily Caregiver Instruction form WORD DOC A form to provide complete information
on your loved one for temporary caregivers/sitters/CNA, etc. who come to your home. Explains routines, special care
instructions,favorite TV schedules, etc.
Daily Needs Assessment Sheet WORD DOC This worksheet will help you and other family
members determine what types of assistance your loved one needs.
A braclet with your medical condition and emergency contacts.
Driving Adaptations
A look at some types of adaptive equipment that may make it easier for your loved one
to drive.
Driving-Losing The Ability to Drive/Article - Generally,
no individual plans for a time when he or she will no longer be able to drive. In fact, your loved one probably assumes that
he or she will know when to stop driving. Most individuals, however, never realize that it is time to stop driving.
Driving Adaptations
A look at some types of adaptive equipment that may make it easier for your loved one
to drive.
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Driving-Alternative Transportation Programs - Making
sure that your loved one has reliable transportation to the doctors office and other important appointments can be one of
a caregivers most difficult tasks. Transportation can be a tough issue for many caregiving families. The issue is even more
difficult if your loved one has mobility problems. Until you have to arrange it, it doesn't seem that something as basic as
getting your loved one to a doctors appointment should be so hard. But for most families, it is. Here's how to begin solving
this problem.
Enter your zip code to learn about alternative transportation in your area.
Guidelines
for Quality Care-Evaluating Quality of Care Checklist (in PDF format) Although there are no "report cards" or accepted
national standards yet available for judging quality end-of-life care, these are some questions
you can ask to evaluate care. These can be used to help select providers and are also helpful if a loved one is dying and
you are uncertain of the quality of care they are receiving. Use this check-list to talk to members of the health care team.
Helpful Forms
Forms in Word document that you can download and modify to meet your needs. For
caregivers, family planning, etc. Although some are written for Huntington's Disease, most are for any situation.
Holiday Help for Caregivers of the Terminally Ill -The
most important consideration of a holiday season is to look for ways to streamline your stress. This site provides some
suggestions.
Excellent links to home modifications and checklists from the National Resource Center
on Supportive Housing and Home Modifications
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and Accessibility -Overall
description of a whole list of things to help with
adaptability and accessibility in your home.
Home Modification-Home or Office Accessible
Homes where you can learn more about adapting your home or office to make it more accessible and convenient for the disabled,
Loans for People With Disabilities, HUD 203k loans available for disability remodeling etc.
Step by step descriptions and diagrams on how to modifiy a bathroom to be handicapped
accessible.
Step by step descriptions and diagrams on how to modifiy a kitchen to be handicapped accessible.
Home Modificiation - Funding Resources - State and Local Funding
- Many states and localities provide special grants and loans to their residents for home. This site offers
suggestions on how to find that funding.
Here is a collection of commonly asked questions received by the National Resource Center
for Supportive Housing and Home Modifications. These questions are dividied into topic categories for your convenience. Information
on:
-Architects/ Contractors
-Government Grants/ Funding
-Assessment Tools/ Instruments
-General Modifications
-Universal Design
-Publication/ Printed Materials
-Products: Bathing, Floors, Grab
Bars, Hearing Impairment,
Lifts, Ramps, Stair Glides, Toileting,
-Assistive Technology
These resources are designed to help consumers make good decisions about the products
they need to improve their home environment. From the Natioinal Resource Center on Supportive Housing and Home Modifications
includes products, catalogs, articles, software etc.
Home Modification - Visitable Homes - Construction guidelines
make homes generally "visitable". Many people with mobility limitations could also occupy these houses with little or no modification.
Because the guidelines are for private, single-family dwellings, or for renovations of houses and apartments not mandated
by existing law, no special "access" codes or additional regulations apply.
A form to complete for every member of your family with complete instructions on medications,
insurance, emergency contacts, etc.
Medical History Chart-Making a Personal One In addition to the
doctors medical history chart, a personal health history is an excellent resource, as it provides a consolidated history of
all medical care and conditions over a stated period of years. Doctors find this information especially useful, even critical,
when prescribing drugs or preparing treatment plans. It can alert them to any complications that might exist based on previous
conditions or medications. A sample chart to help you document your loved one's medical history.
Medicare-Medicaid Payment Options Chart-A summary of many of the services covered by Medicare, Medicaid, and other
government programs These charts may not cover every case possible, and should be used as a reference tool for discussing
your pay options with a local qualified professional
A New Drug Prescription Checklist, questions to ask the doctor.
A form to help you chart eating-related side effects of your loved ones medications. Written
for chemotherapy but usable on any med.
Medication Weekly Check-off Chart (larger version)
Needs Assessment Worksheet
This worksheet will help you and other family members determine what types of assistance
your loved one needs.
A form to help you track rehabilitation goals and successes.
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CULTURAL/DIVERSITY CONSIDERATIONS
African American Perspectives on End of Life - As with other cultural
groups, African Americans' views and behaviors around death and dying are complex and wide-ranging. The Community Ethics Program
(CEP) at the Albert Einstein Healthcare Network is engaged in one effort to explore the attitudes, values and beliefs about
end-of-life care within various ethnic communities.
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