Questionnaire for hiring home care services:

Is the person or agency able to provide the following?

Personal care:

              □ Assist with dressing

              □ Dependent for dressing

              □ Assist with feeding

              □ Dependent for feeding

Personal hygiene:

              □ Bathing: supervision only

              □ Bathing: standby assistance only

              □ Bathing: complete assistance if patient is unable to bathe self

              □ Total bed bath

Transfer assist:

              □ Use of adaptive equipment

              □ Hoyer lift, wheelchair transfer assistance, etc

Toileting:

              □ Stand by assist to and from bathroom

              □ Assist with bedpan use

              □ Assist with cleaning after elimination

              □ Assist to and from bathroom

Administration of medications:

              □ Reminders only

              □ Patient administration with medication placed in cup

              □ Assistance giving medications (oral and rectal route)

Homemaker assistance:

              □ Shopping

              □ Meal planning

              □ Meal preparation

              □ Transportation

              □ Light housekeeping

              □ Laundry and/or linen change

Respite care:

              □ Protective supervision

              □ Safety reminders

              □ Companionship versus hands on caregiving capability

Frequency of services:

              □ Around the clock

              □ Weekend and/or weekday

              □ Consistency of scheduled care givers

END OF LIFE CARE REQUIRES HANDS ON PERSONAL CARE GIVERS;

MAKE SURE YOU KNOW WHAT YOUR PROVIDER IS ABLE TO DO