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Question 1
Has your mom, dad or loved one been diagnosed with any of these conditions?
Heart failure or other heart condition
Stroke
Diabetes
COPD or other respiratory condition
Alzheimer’s/Dementia/Confusion
Cancer
Other
Question 2
Have they experienced any of the following in the past 3 months?
Serious illness (pneumonia, infection, flu)
Joint replacement or surgery (knee, hip, shoulder, etc.)
Falls, dizziness or loss of balance
Trouble eating or swallowing
Depression
Amputation
Question 3
Has your loved one been diagnosed with a terminal condition, with six months or less life expectancy?
YES
NOT SURE
NO
Question 4
Has their doctor prescribed any of the following medications or treatments?
Coumadin/Warfarin (anti-clotting/blood thinner)
Insulin or oral diabetic medication
Pain Medication
IV Medication
IV Medication
Oxygen
Other
Question 5
Does your loved one have trouble keeping track of which medications they’re supposed to take, or have they accidentally taken the wrong medication or dosage?
Frequently – Several times a month
Regularly – At least once a month
Sometimes – A few times a year
Rarely – Once a year or less
Don't know
Question 6
Do they have difficulty performing any of the following tasks?
Bathing
Getting dressed
Preparing food
Using the restroom
Grocery Shopping
Driving
Question 7
How often do they visit or call the doctor to deal with symptoms of their condition or side-effects from medication?
Frequently – Several times a month
Regularly – At least once a month
Sometimes – A few times a year
Rarely – Once a year or less
Don't know
Question 8
How difficult is it for your loved one to leave home? Please select the option that best describes their current situation.
Their condition makes it very difficult or impossible to even leave bed.
Leaving home requires a lot of effort that exhausts them. They leave home infrequently and briefly because of the difficulty.
They use a walker, wheelchair, or require another person’s help to leave home.
They have some difficulty leaving home, but not enough to stop them from going somewhere.
They have no difficulty leaving home.
Question 9
What is the ZIP Code where your mom, dad or loved one lives?
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