Are you deciding on care options for: *

Yourself

Family

Friend

Have they had in-home health care in the past? *

Yes

Have they had an emergency room or hospital visit within the last 30 days? *

Yes

Have they had a recent fall, or a history of falls? *

Yes

How often do they have trouble taking medications the way they have been prescribed? *

They do not have to take medicine

They always take them as prescribed

Sometimes they take them as prescribed

They seldom take them as prescribed

Are they currently taking 5 or more medications? *

Yes

Have they been diagnosed with any of the following? *

Alzheimer’s / Dementia

Stroke

Parkinson’s/MS/ALS

COPD or other respiratory condition

CHF or shortness of breath

Cancer

Diabetes

Back or joint pain

Other

None of the above

In the past 2 weeks, did they struggle with any of the following everyday activities? *

Making meals

Bathing or showering

Grooming

Walking safely

Getting dressed

Using the toilet

Household chores

Getting out of bed

Getting out of a chair

None of the above

When was their last appointment with their Primary Care Physician? *

With the past month

1-3 months ago

More than 3 months ago

Over the past two weeks, how often have they felt down, depressed, or hopeless? *

Not at all

Some days

More days than not

Nearly every day

Are they able to leave their home? *

No difficulty leaving the home

Requires a walker or wheelchair

Requires help from another person

Physically unable to leave the home

First Name

Last Name

Phone *

Email *