* = Required Information

Is your loved one wearing clothing that is dirty or has food stains? YesNo
Does your loved one wear his/her nightclothes during the day? YesNo
Does your loved one wear the same outfit day after day? YesNo
Is it apparent your loved one is not showering or bathing? YesNo
Does your loved one fail to comb/style their hair or brush their teeth? YesNo
Is your loved one losing weight? YesNo
Is there unusual tearing or bruising of the skin that may indicate a fall? YesNo
Does your loved one fail to recognize you or know your name? YesNo
Does your loved one fail to speak normally or have trouble communicating? YesNo
Are there signs of confusion such as not knowing the date, where he/she
is, or, the season of the year?
YesNo
Has your loved one withdrawn socially or is he/she less communicative? YesNo
Are there foul smells coming from the refrigerator and cupboards? YesNo
Are the cupboards void of nutritious food? YesNo
Is the home cluttered and does it have newspapers and mail accumulated? YesNo
Are you finding expired medications or medications that are not being taken? YesNo

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