PLEASE COMPLETE OUR QUICK ASSESSMENT FORM SO WE COULD ASSIST YOU BETTER!   Do you get lost when traveling alone to familiar places? Yes   No Are you feeling anxious or isolated? Yes   No Do you forget to bathe or shower? Yes   No Do you wear the same clothes daily without being washed? Yes   No Are you having difficulty with bladder or bowel control? Yes   No Have you lost weight suddenly? Yes   No Are you missing meals because there is no food in the house or you don’t like eating alone? Yes   No Have you forgotten to refill prescriptions or take medications at prescribed times? Yes   No Is grocery shopping difficult for you? Yes   No Have you had unexplained falls recently? Yes   No Do you have stairs that are difficult to navigate? Yes   No Have you forgotten to deposit checks or pay bills? Yes   No Do you schedule appointments and forget them? Yes   No Do you turn on appliances including the stove and burners and forget to turn them off? Yes   No Have you misplaced items and found them in unusual places? Yes   No       If you answered yes to 1 or more of the above questions and would like further information about geriatric care management services please complete the form below!   Full Name: Phone Number: Email Address: Name of Person who needs assisantance: Relationship to you: Comments:

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