VIVA CHOICES

MEMBER ASSESSMENT TOOL

CLIENT NAME: _____________________________________________
CLIENT AGE: ______________________________________________
CLIENT GENDER: ___________________________________________
ADDRESS:
_________________________________________________________
_________________________________________________________
TELEPHONE NUMBER: _______________________________________
DOES CLIENT LIVE ALONE? __________________________________
IF NO, WHO ELSE RESIDES IN HOME?
_________________________________________________________
_________________________________________________________
ARE THERE IMMEDIATE FAMILY MEMBERS IN THE LOCAL AREA?
_________________________________________________________
HOW OFTEN DO FAMILY MEMBERS HAVE CONTACT WITH CLIENT?
_________________________________________________________
_________________________________________________________
HOW OFTEN DOES CLIENT VISIT WITH FRIENDS?

ARE THERE OTHER SUPPORT SYSTEMS IN PLACE?

_________________________________________________________

CLIENT MEDICAL HISTORY:

WHAT IS CLIENTS CURRENT HEALTH STATUS?
_________________________________________________________
_________________________________________________________
DOES CLIENT HAVE ANY IMMEDIATE HEALTH OR ONGOING HEALTH
CONCERNS?
_________________________________________________________
_________________________________________________________
IS CLIENT ON ANY MEDICATIONS? ________________, IF YES,
WHAT ARE THEY?
_________________________________________________________
_________________________________________________________
IF CLIENT IS ON MEDICATION, DO THEY TAKE MEDICATION
WITHOUT PROMPTING? _______________________________
HISTORY OF HOSPITALIZATION AND SURGERY

WHAT IS CLIENTS LEVEL OF MOBILITY?

_________________________________________________________
_________________________________________________________
WHAT IS CLIENTS VISION LIKE? ____________________________
WHAT IS CLIENTS HEARING LIKE? ___________________________
WHAT IS CLIENTS SPEECH LIKE? _____________________________
SPECIAL EQUIPMENT OR THERAPY ____________________________
________________________________________________________
HAS THE CLIENT FILLED OUT AN ADVANCE DIRECTIVE?
________________________________________________________

PERSONAL HABITS
DOES CLIENT EXPERIENCE SLEEPLINESS> ______________________
DOES CLIENT GET REGULAR EXERCISE? _______________________

WHAT TYPE? _____________________________________________

DOES CLIENT EAT REGULARLY WITHOUT PROMPTING? ____________
DOES CLIENT HAVE DIET RESTRICTIONS? _____________________
IF YES, WHAT ARE THEY? ____________________________________
_________________________________________________________
_________________________________________________________
IS CLIENT ABLE TO DO OWN SELF CARE, IN TERMS OF HYGIENE?
_________________________________________________________
_________________________________________________________
WHAT TYPE OF EMPLOYMENT DID CLIENT DO WHEN THEY WERE IN
THE WORK FORCE?
_________________________________________________________
_________________________________________________________

PHYSICAL fUNCTIONING
WHAT ARE CLIENTS NEEDS IN TERMS OF HOME MAINTENANCE?
WHAT IN HOME NEEDS ARE THERE? __________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
EATING
MEAL PREPARATION
SHOPPING
DRIVING
MOBILITY
TAKING MEDICATION
ASSISTIVE DEVICES
REACHING LIGHT SWITCHES
LAUNDRY________________________
YARD MAINTENANCE _______________
HOME MAINTENANCE (CLEANING) ____________
WATERING PLANTS __________________
MAIL DELIVERY/POSTING__________________
GROCERY SHOPPING _______________
FOOD DELIVERY________________
PERSONAL CHEF ________________(MEALS ON WHEELS)

HOME REPAIRS _____________________

CLIMATE MAINTENANCE (A/C, HEATING) __________________
INTERNET ASSISTANCE AND INSTRUCTION
_________________
ORDERING PRODUCTS __________________________
SECURITY ___________________
BILL PAYING ______________________
WELFARE CHECK (REGULAR PHYSICAL CHECK IN OF CLIENT BY
VIVA STAFF)_____________________________________
COMPANIONSHIP _________________________
PERSONAL TRAINER _______________________
IN HOME MASSAGE _______________________
LIFELINE SERVICES______________________________
OTHER NEEDS
____________________________________________________
____________________________________________________
____________________________________________________

CONTROL OF BLADDER AND BOWELS ___________________________

NIGHT TOILETING _________________________________________
BATHING _________________________________________________
TRANSFERRING TO BED, CHAIR TOILET ________________________
DRESSING ________________________________________________
HAS CLIENT HAD A HOME ACCESSIBILITY ASSESSMENT DONE?
_________________________________________________________

PSYCHOLOGICAL FUNCTIONING:
MENTAL HEALTH HISTORY __________________________________
SHORT TERM MEMORY ______________________________________
LONG TERM MEMORY _______________________________________
SYMPTOMS OF DEPRESSION _________________________________
ANXIETY ________________________________________________
PSYCHOTIC SYMPTOMS _____________________________________
HALLUCINATIONS ________________________________________
BEHAVIORAL DISTURBANCE ________________________________

PETS
DOES CLIENT HAVE PETS? ____________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
ARE PETS FRIENDLY TO VISITORS? ____________________________
WILL THERE BE OCCASIONS IN WHICH CARE IS NEEDED FOR PETS?
_________________________________________________________
_________________________________________________________
DO PETS NEED TO BE TRANSPORTED FOR VETERINARY CARE?
_________________________________________________________

TRANSPORTATION
DOES CLIENT DRIVE? ______________________________________
DOES CLIENT NEED ASSISTANCE MAINTAINING VEHICLE? ________
DOES CLIENT NEED ASSISTANCE WITH TRANSPORATION? ________
IF YES, UNDER WHAT CIRCUMSTANCES WOULD TRANSPORATION BE
NEEDED?
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

RECREATION/SOCIALIZATION
WHAT ACTIVITIES DOES CLIENT ENJOY?
_________________________________________________________
_________________________________________________________
_________________________________________________________
WHAT PHYSICAL ACTIVITY DOES CLIENT PARTICIPATING IN?
_________________________________________________________
_________________________________________________________
DOES CLIENT NEED ASSISTANCE TO PARTICIPATE IN THIS
ACTIVITY? _______________________________________________

DOES CLIENT ATTEND CHURCH? ______________________________

IF YES, DOES CLIENT NEED SUPPORT WITH TRANSPORATION? _____
DOES CLIENT PARTICIPATE IN LOCAL SENIOR ACTIVITIES OR TRIPS?
_________________________________________________________

REAL ESTATE/ASSETS
DOES CLIENT OWN THEIR OWN HOME? ________________________
IS CLIENT INTERESTED IN REVERSE MORTGAGE?_________________
DOES CLIENT HAVE LIFE INSURANCE? _________________________
WHAT CONDITION IS CLIENTS HOME CURRENTLY IN?
_________________________________________________________
_________________________________________________________
IS THERE A MORTGAGE? ____________________________________
HAS IT BEEN TERMITE INSPECTED? ___________________________
WHO DECISION IS IT WHETHER OR NOT TO SELL? ______________
IS CLIENT COMFORTABLE TALKING WITH BOOMER RESIDENTIAL
SPECIALIST?
HAS THE CLIENT HAD A HOME SAFETY ASSESSMENT DONE?

CLIENT PERSONALITY
WHAT ARE CLIENTS SPECIFIC LIKES/DISLIKES THAT MAY AFFECT
THE WAY WE PROVIDE SERVICES TO THEM?
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
___________________________________________________
WHAT IS CLIENTS GENERAL DISPOSITION? (E.G. POSITIVE,
PESSIMISTIC, SUNNY, MOODY, EASY GOING, HIGH STRUNG?)
_________________________________________________________
_________________________________________________________
_________________________________________________________
DOES CLIENT ENJOY THE OUTDOORS OR PREFER BEING INDOORS?

_________________________________________________________
_________________________________________________________
_________________________________________________________
WHAT TYPE OF WEATHER DOES CLIENT ENJOY MOST?
_________________________________________________________
_________________________________________________________
_________________________________________________________
IS CLIENT PRONE TO ASK FOR ASSISTANCE IF THEY NEED IT?
_________________________________________________________
_________________________________________________________

INSURANCE/FINANCIAL:
DOES THE CLIENT HAVE A LONG TERM CARE POLICY?
_________________________________________________________
DOES THE CLIENT HAVE A LIFE INSURANCE POLICY?
_________________________________________________________
DOES THE CLIENT HAVE A BURIAL POLICY?
_________________________________________________________
DOES THE CLIENT HAVE A TRUST?
_________________________________________________________
DOES ANYONE HAVE POWER OF ATTORNEY FINANCIAL - MEDICAL?
_________________________________________________________

ADDITIONAL CONCERNS AND COMMENTS:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
DATE FOR FOLLOW UP WITH MEMBER: _________________________

MEMBER RECOMMENDATIONS AND CHECKLIST

MEDICAL:
________________________________________________________
________________________________________________________
________________________________________________________
PERSONAL HABITS:
________________________________________________________
________________________________________________________
________________________________________________________
PHYSICAL FUNCTIONING:
________________________________________________________
________________________________________________________
________________________________________________________
PSYCHOLOGICAL FUNCTIONING:
________________________________________________________
________________________________________________________
________________________________________________________
PETS:
________________________________________________________
________________________________________________________
________________________________________________________
TRANSPORTATION:
________________________________________________________
________________________________________________________
________________________________________________________

RECREATION/SOCIALIZATION:
________________________________________________________
________________________________________________________
________________________________________________________
REAL ESTATE/ASSETS:
________________________________________________________
________________________________________________________
________________________________________________________
CLIENT PERSONALITY:
________________________________________________________
________________________________________________________
________________________________________________________
INSURANCE/FINANCIAL:
________________________________________________________
________________________________________________________
________________________________________________________
ADDITIONAL:
________________________________________________________
________________________________________________________
________________________________________________________