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Who are you considering home care for? ----- Myself Mother Father Spouse Other Family Member Friend
Do you currently live alone? --- Yes No
Does your Father live alone? --- Yes No
Does your Mother currently live alone? --- Yes No
Does your Spouse currently live alone? --- Yes No
Does your Other Family Member currently live alone? --- Yes No
Does your Friend currently live alone? --- Yes No
Are you concerned about your ability to be safe at home? --- Yes No
Are you concerned about your spouse’s ability to be safe at home? --- Yes No
Are you concerned about your mother’s ability to be safe at home? --- Yes No
Are you concerned about your father’s ability to be safe at home? --- Yes No
Are you concerned about your family member’s ability to be safe at home? --- Yes No
Are you concerned about your friend’s ability to be safe at home? --- Yes No
Do you have any memory issues or dementia? --- Yes No
Does your spouse have any memory issues or dementia? --- Yes No
Does your mother have any memory issues or dementia? --- Yes No
Does your father have any memory issues or dementia? --- Yes No
Does your family member have any memory issues or dementia? --- Yes No
Does your friend have any memory issues or dementia? --- Yes No
Do you have trouble walking or have you fallen recently? --- Yes No
Does your spouse have trouble walking or has fallen recently? --- Yes No
Does your mother have trouble walking or has fallen recently? --- Yes No
Does your father have trouble walking or has fallen recently? --- Yes No
Does your other family member have trouble walking or has fallen recently? --- Yes No
Does your friend have trouble walking or has fallen recently? --- Yes No
Do you ever forget to take medications? --- Yes No
Does your spouse ever forget to take medications? --- Yes No
Does your mother ever forget to take medications? --- Yes No
Does your father ever forget to take medications? --- Yes No
Does your other family member ever forget to take medications? --- Yes No
Does your friend ever forget to take medications? --- Yes No
Do you need help bathing or dressing? --- Yes No
Does your spouse need help bathing or dressing? --- Yes No
Does your mother need help bathing or dressing? --- Yes No
Does your father need help bathing or dressing? --- Yes No
Does your other family member need help bathing or dressing? --- Yes No
Does your friend need help bathing or dressing? --- Yes No
Do you need help with cooking or meal preparation? --- Yes No
Does your spouse help with cooking or meal preparation? --- Yes No
Does your mother help with cooking or meal preparation? --- Yes No
Does your father help with cooking or meal preparation? --- Yes No
Does your other family member help with cooking or meal preparation? --- Yes No
Does your friend help with cooking or meal preparation? --- Yes No
Do you need help with laundry and light housekeeping? --- Yes No
Does your spouse need help with laundry and light housekeeping? --- Yes No
Does your mother need help with laundry and light housekeeping? --- Yes No
Does your father need help with laundry and light housekeeping? --- Yes No
Does your other family member need help with laundry and light housekeeping? --- Yes No
Does your friend need help with laundry and light housekeeping? --- Yes No
Do you ever need help getting to doctors’ appointments or to do shopping? --- Yes No
Does your spouse ever need help getting to doctors’ appointments or to do shopping? --- Yes No
Does your mother ever need help getting to doctors’ appointments or to do shopping? --- Yes No
Does your father ever need help getting to doctors’ appointments or to do shopping? --- Yes No
Does your other family member ever need help getting to doctors’ appointments or to do shopping? --- Yes No
Does your friend ever need help getting to doctors’ appointments or to do shopping? --- Yes No
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