Section A - Basic Demographics

First Name *

Middle Name

Last Name *

Gender *

Female

Male

Unspecified

Date of birth *

Address

Street Address *

City *

State *

Country *

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal code *

Mobile Number *

Home Phone

Work Phone

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

Signed Social Security Document

Section B - Social History

Race *

American, Indian or Alaska Native

Asian or Asian American

Black or African American

Native Hawaiian or Pacific Islander

White

Other

Ethnicity *

Hispanic or Latino

Non Hispanic

Household Size *

I live alone

I live with others

Section C - Financial

Living situation *

I live alone

I live with my spouse

Section C - Financial

My income is between *

$1,304/month or less

$1,305 - $1,956/month

$1,957 - $2,608/month

More than $2,608/month

Section C - Financial

Our income is between *

$1,763/month or less

$ 1,764 - $2,644/month

$2,645 - $3,525/month

More than $3,525/month

Section D - Emergency Contacts

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Section E - Activities of Daily Living

Can you bathe or shower without help? *

Yes

Can you walk around inside without any help? *

Yes

Can you sit up or move around in bed without help? *

Yes

Can you use the toilet without help? *

Yes

Can you comb your hair, shave, wash your face, or brush your teeth without help? *

Yes

Can you dress without help? *

Yes

Can you get in and out of bed or a chair without help? *

Yes

Can you manage eating without help? *

Yes

Section F - Independent Activities of Daily Living

Can you answer the telephone or make a phone call on your own? *

Yes

Can you do heavy house cleaning, like yard work and laundry, without any help? *

Yes

Can you shop for food and other things, without any help? *

Yes

Can you take medication without help? *

Yes

Can you prepare meals for yourself without help? *

Yes

Can you handle your own money, like keeping track of bills without any help? *

Yes

Can you do light housekeeping, like dusting or sweeping, without any help? *

Yes

Can you use public transportation or drive beyond walking distance without any help? *

Yes

Social Determinants of Health

Are you able to make new friends? *

Yes

Have you had any problems joining in community activities? *

Yes

Do you have any problems doing things by yourself for relaxation or pleasure? *

Yes

Is it difficult for you to pay for food, housing, medical care and your heat? *

Yes

Do you have times when you can't afford more food? *

Yes

Have you run out of food before? *

Yes

Has the lack of transportation limited you in getting food, medications, or to a medical appointment? *

Yes

Do you exercise daily? *

Yes

Have you experienced abuse in any form recently? *

Yes

Do you drink alcohol? *

Yes

Do you use tobacco? *

Yes

Live Well At Home Rapid Screen®

Do you need help to do the following? *

Walking

Getting out of bed/chair

Going to the bathroom

Bathing

Dressing

Eating

During the last 6 months, have you had a fall that caused injuries? *

Yes

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.

Do you have a family member/friend give you help when you need it? *

Yes

Does your caregiver feel overwhelmed or stressed because of the care they provide you? *

Yes

Have you thought about moving to other housing? *

Yes

If yes to previous question, where have you considered moving to?

Nursing Home

Assisted Living

Do you live alone? *

Yes

Do you or your family have concerns about your memory, thinking, or ability to make decisions? *

Yes

If Yes to previous question, are you

Very concerned

Somewhat concerned

Not concerned

Live Well At Home Rapid Screen®

Services for older adults

Adult Day Services

Alzheimer's Association

Assistive Technology | RPM| Zempler

Call-in reassurance program

Care Coordination/Management Services

Caregiver consultation

Caregiver Support Program or Service

Chore Services

Chronic Disease Self-Management Program

Community integration / socialisation

Companion Services

Counseling and/or planning support

Falls prevention program

Family Memory Care Program

Fiscal support entity services

Food Shelf

Grocery shopping / delivery

Health status checks

Hearing loss services

Home care

Homemaker Services

Home Modification / Repair Services

Home safety

Housekeeping

Incontinence support

Live Well at Home provider / risk support

Long Term Care Consultation

Low income housing

Meals

Medical supplies / equipment

Medication Management Program

Memory Care services / support and resources

Medication support

MNHelp.info

Personal care

Personal Emergency Response Systems

Physician

Powerful Tools for Caregivers

Private purchasing of in-home support/help without FSE

Rehabilitation therapies

Respite services

Self-Directed Services with Fiscal Support Entity (FSE)

Senior LinkAge Line

Specific housing

TCARE(R) caregiver assessment

Transportation

Vision loss services

Wellness program

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.

Do you agree for your information to be used as stated above? *

Yes

Signature *

Clear

Date Signed *