Date

MM

DD

YYYY

Completed by:

Self

Caregiver

Age Group (Select one):

Young-Old: 65 to 74

Old-Old: 75 to 84

Oldest-Old: 85+

Overall Wellness: Select the most appropriate fit:

Very fit, robust, active, energetic, motivated.

Well, active occasionally, no active disease symptom but less fit than 1 .

Medical problems are well controlled, no extensive activity.

Increased fatigue, activities limited by progression.

Mild frailty, help with shopping, walking outside alone, meal prep and housework.

Help with all oustide activites, keeping house. Problems with stairs, help with personal care.

Completely dependent for personal care. In stable health.

Severely frail – completely dependent. Could not recover from minor illness.

Living Situation: Do you live alone?

Yes

No

Driving and Location: Do you drive?

Yes

No

Which area do you live in?

Ocean Grove South

Willow Point

Central

Discovery

Health and Medications: Do you have a Family Physician?

Yes

No

How many daily medications do you take:

0

1-5

6-9

9-12

Have you created the following personal planning documents? Advance Directive (Your healthcare wishes in writing):

Yes

No

Representation Agreement (Appoints someone to help with personal, health, or legal decisions):

Yes

No

Power of Attorney (Appoints someone for financial decisions):

Yes

No

End-of-Life and Legacy Planning: Have you thought about or initiated any of the following end of life plans?

(Select all that apply):

The type of care I would want to receive at the end of life

Who I would want to make decisions if I was no longer able to do so

Discussing my wishes and values with loved ones

Making funeral arrangements

Writing a will or advance directive

I haven’t thought about any of these yet

Purpose and Autonomy: I feel a strong sense of purpose and fulfillment in my daily activities and choices.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I feel a sense of autonomy and control over decisions about my care and how I live my life.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

Wishes and Values: My wishes and values are realistic and clearly communicated to those involved in my care.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I enjoy socializing with others, but also feel that I have the personal time and space I need.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I understand the trajectory of aging and feel prepared for the changes it may bring.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I feel confident and comfortable with the idea of long-term care, should I require it in the future.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

Social Opportunities: I have enough opportunities to connect socially with others in ways that are meaningful to me.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

System Navigation, Health, and Rehabilitation: I feel supported in managing my health and medication planning, including accessing healthcare services when needed.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I feel confident navigating the healthcare or community support systems to access the services I need.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I feel supported in accessing rehabilitation or therapy services that help me maintain my health and mobility.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

Housing: My current living arrangements feel safe, comfortable, and suited to my needs.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I feel confident that my home is accessible and set up to support my independence.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

Budget and Financial Efficiency: I feel confident that I can afford to access the services and support I need.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I can afford basic necessities like food, housing, and medications.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

Food and Nutrition: I feel content with my food and drink choices and have access to meals that meet my dietary needs.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I can easily access fresh and nutritious food, whether by preparing it myself or through delivered options.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

Transportation: Rides and transportation are not a barrier for me when it comes to attending appointments or social activities.

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10

I feel confident and comfortable navigating public or private transportation options to meet my needs. 1 (Strongly Disagree) to 10 (Strongly Agree):

Please rate the following on a scale from 1 (Strongly Disagree) to 10 (Strongly Agree):

1

2

3

4

5

6

7

8

9

10