Care Questionnaire

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.)?

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

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

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

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

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

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?

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