Logan Acres Senior Community Memory Care Information Request Form

Please answer the following questions so we can help determine which level of care we provide is right for you.

1. What level of assistance is needed from someone to move about in your residence or the community? *

2. What type of supervision is needed when eating or must he/she be fed by others? *

3. What level of assistance is needed for dressing? *

4. What level of assistance is needed for daily hygiene and grooming? *

5. Are you or your loved one dependent upon others for bathing/showering? *

6. Are you or your loved one dependent upon others for your toileting needs? *

Yes No

7. How do you make sure medications are safely administered? *

8. Have you or your loved one been diagnosed with a terminal illness that requires Hospice care? *

Yes No

9. Is your loved one disoriented to person, place and time? *

Yes No

10. Do you or your loved one become anxious, combative or verbally or physically abusive? *

Yes No

11. Are you or your loved one unable to walk alone? *

Yes No

12. Have you or your loved one had a recent fall? *

Yes No

13. Do you or your loved one receive Medicaid benefits in the community? *

Yes No

14. Do you or your loved one use a walker or wheel cchair to assist with transfers or walking? *

Yes No

Please provide your information below so we have a way to contact you.

If requesting info on behalf of someone else, please list their name and your relationship to that person.

Name of Person Requesting Info For *

First

Last

Your relationship to person you're requesting info for: *

Is Dementia Care Right For You?