SELF-ASSESSMENT
| IS HOME FOR LIFE SOLUTIONS APPROPRIATE FOR YOU AND YOUR LOVED ONE? | Please check each box that is relevant to you and add your total score. |
| 1. Do you spend more than two hours alone during the day and/or night? | 2 pts |
| 2. Is it important for you to remain independent in your home? | 3 pts |
| 3. Would knowing you are monitored in your home 24 hours a day, seven days a week, give you peace of mind? | 1 pts |
| 4. Do you require assistance with activities of daily living such as bathing, toileting, dressing, meal prep, etc.? | 3 pts |
| 5. Do you use an assistive device to help with walking or balance (i.e. cane, walker, etc.)? | 3 pts |
| 6. Do you take at least two or more medications daily? | 3 pts |
| 7. Do you have one or more of the following chronic ailments: COPD, CHF, stroke, diabetes, heart disease, arthritis, etc.? | 2 pts |
| 8. Have you been hospitalized or gone to the emergency room in the past six months? | 2 pts |
| 9. Have you fallen or been at risk of falling in your home? | 3 pts |
| NEED FOR TELECARE SERVICES | Total Points |
| 15-20 Points: IMMEDIATE NEED Telecare services are likely to be recommended with some amount of urgency by health care professionals in this situation. 8-14 Points: HIGH NEED Telecare services are likely to be recommended by health care professionals in this situation. 4-7 Points: MODERATE NEED Health care professionals will advise you to consider telecare services. 0-3 Points: LIMITED NEED The need for services like Home For Life Solutions may not be required immediately but should be re-evaluated from time to time.  |
Home For Life Solutions is a telecare system that monitors the daily actions and environment of older adults through integrated products and services without invading their privacy. This questionnaire is helpful in identifying the possible need for our telecare services. |