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Is your loved one wearing clothing that is dirty or has food stains? Yes No Does your loved one wear his/her nightclothes during the day? Yes No Does your loved one wear the same outfit day after day? Yes No Is it apparent your loved one is not showering or bathing? Yes No Does your loved one fail to comb/style their hair or brush their teeth? Yes No Is your loved one losing weight? Yes No Is there unusual tearing or bruising of the skin that may indicate a fall? Yes No Does your loved one fail to recognize you or know your name? Yes No Does your loved one fail to speak normally or have trouble communicating? Yes No Are there signs of confusion such as not knowing the date, where he/she is, or, the season of the year? Yes No Has your loved one withdrawn socially or is he/she less communicative? Yes No Are there foul smells coming from the refrigerator and cupboards? Yes No Are the cupboards void of nutritious food? Yes No Is the home cluttered and does it have newspapers and mail accumulated? Yes No Are you finding expired medications or medications that are not being taken? Yes No

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