Care Questionnaire

What type of care do you need?

Take our Care Questionnaire to help determine which type of care may be the best option for you or your loved one.

After completing the questionnaire, you can discuss your results with a senior resource consultant and schedule a full assessment† to discover what care is right for you.

I am taking this Care Questionnaire for:

MyselfMy ParentMy SpouseSomeone Else

Are you or your loved one experiencing any of the following? (Check all that apply or if none, click next)

Trouble Hearing/Hearing LossLow Vision/Difficulty SeeingDifficulty WalkingDifficulty EatingDepressionFalling or Unsteadiness

Have you or oyur loved one stayed in any of the following in the last 6 months? (Check all that apply or if none, click next)

HospitalRehab/Skilled Nursing FacilityAssisted Living FacilityIn-Patient Stay

Are you or your loved one still under a doctor's prescribed regime/care plan?

YesNo

Do you or your loved one need someone to help you with any of the following? (Check all that apply or if none, click next)

Getting DressedBathingUsing the BathroomPreparing MealsTaking MedicationsGetting to the Doctor's Office

Do you have difficulty remembering things such as paying your bills each month?

YesNo

Have you ever been diagnosed with dementia or Alzheimer's?

YesNo

Have you ever wandered or driven away from a known location and felt disoriented or lost?

YesNo

Do you have additional information to share? (Optional):

Name
E-mail*
Phone Number*

Area CodePhone Number
Should be Empty: