Care Assessment Questionnaire
Please click on the Submit button to submit the form details.
*
indicates required fields
Do you live alone?:
Yes
No
Do you use assistance devices?:
Yes
No
Have you been hospitalized in the past year?:
Yes
No
If yes, How many times?:
0
1
2
3
4
5
6
7
8
9
10
What was the reason?:
Do you take prescription medications?:
Yes
No
Do you need help to walk, bathe, dress, or eat?:
Yes
No
Do you feel socially isolated?:
Yes
No
Can you easily cook, clean, shop, do laundry?:
Yes
No
Have you made care plans if you can't speak?:
Yes
No
Do you need someone to check on you medically?:
Yes
No
Have home safety hazards been removed?:
Yes
No
Do you have memory or judgement problems?:
Yes
No
Are you losing weight?:
Yes
No
Do you have difficulty moving around?:
Yes
No
Is it hard for you to bathe or dress yourself?:
Yes
No
Can you cook full meals everyday?:
Yes
No
Can you do your own laundry?:
Yes
No
Do you need transportation to places?:
Yes
No
Do you worry how to take care of your house?:
Yes
No
Do you want to know more about our services?:
Yes
No
*
Your Name:
*
Your Phone Number:
Your Email Address:
Your Address:
Specific Location Details:
Please click on the Submit button to submit the form details.
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