Section A - Basic Demographics

Country

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company.

Section B - Social History

Section C - Financial

Section C - Financial

Section C - Financial

Section D - Emergency Contacts

Section E - Activities of Daily Living

Section F - Independent Activities of Daily Living

Social Determinants of Health

Live Well At Home Rapid Screen®

NOTE: "Injuries" means fracture or joint dislocation, head injuries resulting in loss of consciousness and hospitalization, joint injuries that led to decreased activity, internal injuries that led to hospitalization OR 3 or more of any falls.

Live Well At Home Rapid Screen®

Use of Information

I understand that the information I am providing on this form is for registration purposes. The information will be used by the U.S. Health and Human Services Administration for Community Living (ACL), the Minnesota Board on Aging (MBA) and the local Area Agency on Aging to create statistical reports. ACL, MBA and/or its assignees may use this information to conduct a study and/or survey of this service. In addition, information provided here, may be used by other service providers to help identify other services from which I may benefit. This information will not be released to anyone other than the above-mentioned parties in a way that will identify me as an individual unless I sign a separate consent for that purpose.