The information you supply is essential for Crestone to develop an understanding of your CURRENT SITUATION.

As Healthcare Professionals, Crestone complies with all the requirements and conditions of the HIPAA Act which protects your privacy regarding personal and health information.

Crestone will evaluate your responses and reply to you by Email with recommendations within 3 working days at no cost.

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




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