Coventry RI nursing Home

Contact us at Riverview

Selecting a senior care provider can be a difficult task. However, identifying the particular needs of your elderly loved one, will help in making informed decisions as to which facility can best meet their requirements. The following Form can assist you with that Needs Assessment and assist us in answering the questions you may have.

Once completed, click the "submit" button so we can contact you with a personalized summary report will be generated that you can use as your "needs" checklist.

Nursing Home Needs Assessment Survey

Why Do You Need A Nursing Home?

Individual can no longer care for him/herself
Individual requires more care than can be provided by our family
Individual has extensive medical needs
Physician recommendation
Discharged from hospital and requires temporary skilled care before returning home

Individual Currently Has The Following Medical Needs: (Check as many as apply)

Nursing Care Level Requirements

Supervision only
Assistance with daily living activities
Therapy
24-hour nursing
Intensive nursing
Other

Medical Conditions

Alzheimer's disease
Cancer
Cardiovascular disease
Chronic pain
Dementia
Developmentally disabled
Head trauma
Hematologic condition
Mental disease
Neurological disease
Neuromuscular disease
Orthopedic/skeletal problems
Pulmonary disease
Para/quadriplegic
Stroke
Trauma
Wound
Other

Therapies Recommended By Physician

Physical therapy
Occupational therapy
Speech therapy
Respiratory therapy
Reality therapy
Other

Equipment and Supplies

Wheel chair
Prosthetics
Ventilator
Special bed
Intravenous drugs
Prescription drugs
Medical supplies
Oxygen
Other

Other Medical Specialists Needed on a Regular Basis

Dentist
Dietician
Opthamologist
Physician
Podiatrist
Other

Individual Requires Help With The Following Activities of Daily Living

Personal care
Bathing
Continence
Dressing
Eating
Mobility
Toileting
Using the telephone
Shopping
Preparing meals
Housekeeping
Laundry
Transportation
Taking medications
Handling finances
Other

Cultural and Social Needs

Language (if not English)
Culturally-based special diet
Medically prescribed special diet
Other

Religious affiliation

Social activities preferred

Cards and games
Movies
Prayer groups
Arts and crafts
Television
Reading
Pet therapy
Social events
Outdoor activities
Interaction with others
Other

Financial - How Will You Pay For Care?

Private pay
Medicare
Medicaid
Veteran's benefits
Private long-term care insurance
HMO or managed care
Other

Legal

Does the individual have a will? Yes No
Is a durable power of attorney in place? Yes No
Any life support directives? Yes No
Does the individual have a living will? Yes No

Patient Information (optional)

Patient name
Physician name
Age

Your Contact Information (required)

Contact name
Street address
City
State
Zip code
Contact telephone
Contact E-mail


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