The Care Test

Indictators for Companion Care?

* Indicates required field

Name *

First

Last

Phone Number *

Email *

1. Increased forgetfulness and memory issues, such as missing appointments or skipping medications. *

Yes No

2. Behavioral changes, mood swings, irritability, or unusual quietness. *

Yes No

3. Poor personal hygiene, such as unclean clothing or unkempt appearance *

Yes No Other

4. Unkempt home environment, with signs of neglect in housekeeping or home maintenance *

Yes No

5. Difficulty with meal preparation or poor nutrition *

Yes No

6. Social withdrawal and isolation, including a shrinking social circle. *

Yes No

7. Safety concerns, such as wandering or getting lost, especially for those with dementia symptoms. *

Yes No

8. Inability to perform basic household chores or light housekeeping tasks. *

Yes No

9. Recent health changes, such as recovery from surgery or discharge from a rehabilitation center. *

Yes No

10. Living alone without regular check-ins from nearby family members. *

Yes No

11. Difficulty with transportation or inability to drive safely. *

Yes No

12. Signs of cognitive decline, such as confusion or lapses in memory. *

Yes No

13. Physical health decline, including weight loss, frailty, or difficulty walking. *

Yes No

14. Loneliness and changes in emotional state. *

Yes No

15. Struggling to orientate within the community or complete basic tasks. *

Yes No

16. Balance issues or frequently falling. *

Yes No

Submit

“Yes” Indicates that you may benefit from
My Best Companions services.