Senior Care Calculation Form
Provide details to assess and estimate suitable senior care services and costs.
Senior's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Living Arrangement
*
Living alone
With family
Assisted living facility
Nursing home
Other
Health & Mobility Status
*
Rows
Independent
Needs some assistance
Requires full assistance
Mobility
1
2
3
Personal hygiene
4
5
6
Medication management
7
8
9
Meal preparation
10
11
12
Medical Conditions (select all that apply)
Diabetes
Hypertension
Dementia/Alzheimer's
Heart disease
Arthritis
Other
Type of Care Services Needed
*
Personal care (bathing, dressing, grooming)
Meal preparation
Medication reminders
Housekeeping
Transportation
Companionship
Other
How often are care services needed?
*
24/7 (live-in)
Daily
A few times per week
Occasionally
Estimated Monthly Budget for Care
*
Is there long-term care insurance?
Yes
No
Not sure
Primary Contact Name
*
First Name
Last Name
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Notes or Special Requirements
Calculate Care Needs
Should be Empty: