I am completing this questionnaire for:

Myself Spouse Parent Other

Do you (or your loved one) currently need in-home support 24 hours per day?

Yes No

Do any of the following apply to you (or your loved one)?

  • Difficulty walking and/or getting in or out of bed (or a chair)?
  • Trouble eating the right amount of food, keeping a balanced diet, and/or physical barriers to eating properly?
  • Unsteady and/or prone to falling?
  • Trouble getting dressed and/or grooming?
  • Trouble toileting or bathing?
  • Trouble taking and/or managing medication?
Yes No

Have you (or your loved one):

  • Stayed at a hospital, skilled nursing or rehab facility, or assisted living facility?
  • Had an inpatient stay in the last six (6) months?
Yes No

Are you (or your loved one) still under the care of a doctor based on your previous facility stay and/or inpatient experience?

Yes No

Have you (or your loved one) ever wandered away from home (on foot or via car) or felt disoriented or lost?

Yes No

Have you (or your loved one) been diagnosed with dementia from possible Alzheimers disease, a stroke or another related health matter?

Yes No

Do you (or your loved one) have trouble remembering things such as paying your bills each month?

Yes No