Senior Care Intolerance Assessment Form
Assess symptoms, possible triggers, severity, and daily-care impact for senior care intolerance. This form is intended for general assessment and planning purposes only.
Assessment Overview
Preferred Name or Initials
*
Age Range
*
Please Select
60-69
70-79
80-89
90+
Prefer not to say
Living Situation
*
At home independently
With family or caregiver
Assisted living
Long-term care community
Other
Main Reason for Completing This Assessment
*
Intolerance Symptoms and Triggers
Rate intolerance indicators by frequency and severity
*
Rows
Frequency
Severity
Discomfort
1
2
Agitation
3
4
Restlessness
5
6
Fatigue
7
8
Confusion
9
10
Dizziness
11
12
Nausea
13
14
Breathing discomfort
15
16
Skin irritation
17
18
Sleep disruption
19
20
Frequency scale
*
Never
1
2
3
4
Very often
5
1 is Never, 5 is Very often
Most common trigger category
*
Meals
Medications
Mobility assistance
Bathing
Noise
Temperature
Lighting
Routine changes
Other
Impact and Follow-up
Which daily care activities are affected?
*
Eating
Bathing
Dressing
Walking
Medication routine
Sleeping
Social interaction
Other
How long has this issue been noticed?
*
Less than 1 week
1–4 weeks
1–3 months
More than 3 months
Not sure
Preferred support or follow-up
*
Monitor for now
Caregiver review
Schedule consultation
Adjust routine
Other
Additional notes or context
Submit Assessment
Should be Empty: