  Number of Doctors who write prescriptions for you Number of Prescriptions, over-the-counter drugs, vitamins and herbal remedies you are taking Number of Pharmacies (stores) where you buy prescriptions, over-the-counter drugs, vitamins and herbal remedies 1) Does individual need help with any of the following: (click on boxes that apply) eating dressing toileting continence bathing transferring 2) Does individual need help with any of the following: (click on boxes that apply) driving shopping managing money doing laundry meal preparation managing medications doing housework balance or mobility using telephone other 3) Do any of the following affect the individual's ability to function: (click on boxes that apply) hearing vision confusion memory disoriented agitated wandering expressing thoughts energy arthritis heart disease osteoporosis other 4) Areas of home/living environment that may not be safe: (click on boxes that apply) obstacles or clutter overall condition of house adequate lighting bathroom kitchen stairs floors furnishings doors or windows 5) Medication Safety Checkup: (check on boxes that apply) communicate regularly with doctors and pharmacies store medications properly take all medications as prescribed and labeled drive while taking medications that cause drowsiness, confusion or affect alertness know side effects of ALL medications know drugs for older adults to avoid do not take or are unsure if taking duplicate medications know why taking ALL medications know that ALL medications are appropriate for my diagnoses Comments |