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2018 Annual Gingerbread Challenge Highlights!
January 17, 2019
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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
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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
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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?
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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
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Do you find yourself worrying about your loved one’s current living situation?
Yes
No
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Is the care and maintenance of the home becoming a burden?
Yes
No
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Would your loved one benefit from in-home support with health needs?
Yes
No
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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
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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
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Is your loved one struggling with challenges related to dementia?
Yes
No
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Does your loved one have difficulty remembering their surroundings or things that have happened recently?
Yes
No
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Is there anything else you’d like to share?
Is there anything else you’d like to share?
SEE RESULTS
