Family Guided Aging Evaluation - PASE of Well Being - Senior Kare Expert by Stacey K Eisenberg

Parent Aging Self- Evaluation (PASE) of Well Being

To assess the overall well-being of aging parents, identify potential issues early, and facilitate discussions with healthcare providers if needed.

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Instructions: For each question, rate on a scale of 1 to 10 (1 = not at all, 10 = excellent). Use the notes section to add specific observations or concerns. Do this every 6 months to a year to monitor the aging process.

This form has been designed so that you can start it, save it and return to it later.

Name

First

Last

Physical Health

How steady is their balance when walking or standing?

Selected Value: 0

How well are they managing chronic conditions or medical issues (e.g., diabetes, arthritis, recent significant weight loss or gains, managing all their prescriptions, getting to their medical appointments)?

Selected Value: 0

Are they eating a healthy, balanced diet regularly?

Selected Value: 0

How frequently are they physically active (e.g., walking, exercising)?

Selected Value: 0

Do they live in a safe home environment free from hazards (have you had a safety evaluation)?

Selected Value: 0

Physical Health Notes and Concerns

(e.g., communicate

Physical Health Score

Cognitive and Emotional Well-Being

How is their memory and ability to recall recent events?

Selected Value: 0

Are they able to communicate their needs and feelings effectively?

Selected Value: 0

Do they show signs of emotional stability and positive mood?

Selected Value: 0

How engaged are they in solving problems or making decisions?

Selected Value: 0

Do they show interest in hobbies or activities they used to enjoy?

Selected Value: 0

Cognitive and Emotional Well-Being Notes and Concerns

Cognitive and Emotional Well-Being Score

Social Engagement

How often do they interact with friends, family, or neighbors?

Selected Value: 0

Do they participate in community events or groups?

Selected Value: 0

Are they able to maintain healthy relationships with loved ones?

Selected Value: 0

Do they seek or accept help when needed?

Selected Value: 0

How willing are they to try new activities or meet new people?

Selected Value: 0

Social Engagement Notes and Concerns

Social Engagement Score

Daily Living and Independence

How well do they manage personal care (e.g., bathing, grooming, dressing)?

Selected Value: 0

Are they able to prepare meals or handle basic household tasks?

Selected Value: 0

Are their financial matters, such as paying bills, in order or do they fall for scams regularly?

Selected Value: 0

How well do they adapt to changes in routine or unexpected events?

Selected Value: 0

How well are they able to access and use transportation (drive themselves or use public transportation)?

Selected Value: 0

Daily Living and Independence Notes and Concerns

Daily Living and Independence Score

Total Score

Disclaimer: This evaluation is a self-guided tool and not a substitute for professional medical advice or assessment. For concerns about your parent’s health or safety, consult a healthcare provider or senior care specialist.

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Family Guided Aging Evaluation – PASE of Well Being

Parent Aging Self- Evaluation (PASE) of Well Being

Physical Health

Physical Health is an area of concern, even if the overall score is higher.

Cognitive and Emotional Well-Being

Cognitive and Emotional Well-Being is an area of concern, even if the overall score is higher.

Social Engagement

Social Engagement is an area of concern, even if the overall score is higher.

Daily Living and Independence

Daily Living and Independece is an area of concern, even if the overall score is higher.