Assisted Living Pre-Screening Questionnaire
UPDATED 2022
Use Briggs Pre-Screening Questionnaire is used to learn more about the needs and services to meet those needs of a prospective Assisted Living resident, including:
| • | Current and prior living situation |
| • | Bathing, Dressing, Oral Care, Hair Care |
| • | Ambulation |
| • | Prosthesis |
| • | Waking Up/Getting Out of Bed, Sleeping |
| • | Preparing for Bed/Getting Into Bed |
| • | Need for Daytime and/or Nighttime Monitoring |
| • | Toileting |
| • | Special Diet Needs |
| • | Dining/Eating |
| • | Medications - OTC, Prescription, Injections |
| • | Assistance Needed with Personal Affairs/Appointments/Transportation |
| • | Social/Activities |
| • | Housekeeping |
| • | And other important Physical/Social Considerations |
• 8 1/2" x 11"
• White paper, black ink
• Printed two sides different
• 3-hole side punched
• Padded in 100s
• White paper, black ink
• Printed two sides different
• 3-hole side punched
• Padded in 100s