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Lifestyle Questionnaire
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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?
Yes
No
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Do you think your children and family have concerns or are losing sleep over your current living situation?
Yes
No
back
Would you like to be around people with common interests?
Yes
No
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Is the care and maintenance of your home becoming a burden?
Yes
No
back
Do you require in-home support throughout the day?
Yes
No
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Are you experiencing any of the following? Check all that apply:
Trouble hearing/Hearing Loss
Low Vision/Difficulty Seeing
Difficulty Walking
Difficulty Eating
Depression
Falling
Loneliness
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Have you stayed in any of the following in the last 6 months? Check all that apply
Hospital
Rehabilitation Facility
Assisted Living Community
Memory Care Community
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Have you ever been diagnosed with a form of dementia?
Yes
No
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Is there anything else you would like to share?
Is there anything else you would like to share?
SEE RESULTS
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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.)?
Yes
No
back
Do you find yourself worrying about your loved one’s current living situation?
Yes
No
back
Is the care and maintenance of the home becoming a burden?
Yes
No
back
Would your loved one benefit from in-home support with health needs?
Yes
No
back
Is your loved one experiencing any of the following? Check all that apply:
Trouble hearing/Hearing Loss
Low Vision/Difficulty Seeing
Difficulty Walking
Difficulty Eating
Depression
Falling
Loneliness
next
back
Has your loved one stayed in any of the following in the last 6 months?
Hospital
Rehabilitation Facility
Assisted Living Community
Memory Care Community
next
back
Is your loved one struggling with challenges related to dementia?
Yes
No
back
Does your loved one have difficulty remembering their surroundings or things that have happened recently?
Yes
No
back
Is there anything else you’d like to share?
Is there anything else you’d like to share?
SEE RESULTS