The Homestead at Hickory View | Lifestyle Questionnaire

I am taking this Lifestyle Questionnaire for:

For Myself

For a Loved One

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Do you wish you had more time to socialize with friends and enjoy leisure activities, versus maintaining your home?

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Do you think your children and family have concerns or are losing sleep over your current living situation?

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Would you like to be around people with common interests?

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Is the care and maintenance of your home becoming a burden?

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Do you require in-home support 24-hours a day?

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Do you find you would benefit from having someone to help with the following tasks?

Getting Dressed Bathing Using the Bathroom Taking Medications Preparing Meals Getting to the Doctor’s Office

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Have you stayed in any of the following in the last 6 months? Check all that apply

Assisted Living Community Rehabilitation Facility Memory Care Community

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Dementia is a general term for a decline in memory and other thinking skills that interferes with a person’s ability to perform everyday activities. Have you been diagnosed with a form of dementia?

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Is there anything else you would like to share?

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Is your loved one doing what they need to do (relative to maintaining a home) versus what they’d rather be doing (socializing with friends, leisure activities, etc.)?

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Do you find yourself worrying about your loved one’s current living situation?

back

Is the care and maintenance of the home becoming a burden?

back

Would your loved one benefit from in-home support with health needs?

back

Is your loved one having trouble with any of the following? Check all that apply:

Bathing Getting Dressed Getting to the Doctor’s Office Preparing Meals Taking Medications Using the Bathroom

back

Has your loved one stayed in any of the following in the last 6 months?

Rehabilitation Facility Assisted Living Community Memory Care Community

back

Dementia is a general term for a decline in memory and other thinking skills that interferes with a person’s ability to perform everyday activities. Has your loved one been diagnosed with a form of dementia?

back

Does your loved one have difficulty remembering their surroundings or things that have happened recently?

back

Is there anything else you’d like to share?

I am taking this Lifestyle Questionnaire for:

For Myself

For a Loved One

back

Do you wish you had more time to socialize with friends and enjoy leisure activities, versus maintaining your home?

back

Do you think your children and family have concerns or are losing sleep over your current living situation?

back

Would you like to be around people with common interests?

back

Is the care and maintenance of your home becoming a burden?

back

Do you require in-home support 24-hours a day?

back

Do you find you would benefit from having someone to help with the following tasks?

Getting Dressed Bathing Using the Bathroom Taking Medications Preparing Meals Getting to the Doctor’s Office

back

Have you stayed in any of the following in the last 6 months? Check all that apply

Assisted Living Community Rehabilitation Facility Memory Care Community

back

Dementia is a general term for a decline in memory and other thinking skills that interferes with a person’s ability to perform everyday activities. Have you been diagnosed with a form of dementia?

back

Is there anything else you would like to share?

back

Is your loved one doing what they need to do (relative to maintaining a home) versus what they’d rather be doing (socializing with friends, leisure activities, etc.)?

back

Do you find yourself worrying about your loved one’s current living situation?

back

Is the care and maintenance of the home becoming a burden?

back

Would your loved one benefit from in-home support with health needs?

back

Is your loved one having trouble with any of the following? Check all that apply:

Bathing Getting Dressed Getting to the Doctor’s Office Preparing Meals Taking Medications Using the Bathroom

back

Has your loved one stayed in any of the following in the last 6 months?

Rehabilitation Facility Assisted Living Community Memory Care Community

back

Does your loved one have difficulty remembering their surroundings or things that have happened recently?

back

Is there anything else you’d like to share?