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Complete this short assessment to let your loved ones enjoy their twilight years.
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Full Name
*
First Name
Last Name
E-mail
Phone Number
*
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Please tell us who you're completing this assessment for?
*
Parent
Spouse
Friend
Family Member
Self
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What is their age?
Under 55
55-64
65-74
75-84
85+
Please tell us about the primary means of payment for their senior living options.
Private payment by resident/senior
Medicaid/state payment
Long-term care insurance
Veterans benefits
Not sure
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What city does the senior currently live in?
*
What city/town would the senior like to live in?
*
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How soon will you be needing to make a decision about senior living options?
*
Within the week
Within the next 30 days
Within 30-60 days
Within 60-90 days
Not sure
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Please indicate any health conditions you are aware of for this person.
Arthritis
Cancer - Active Treatment
Cancer - Survivor
Stroke
Open Wounds
Forgetfulness
Dementia
Alzheimer's
Diabetes
Chronic hip, knee, back pain
Don't know
None of the Above
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Please indicate if the person has been in the hospital, rehabilitation center or nursing home in the last three (3) months.
Yes
No
Don't Know
Hospital
Rehabilitation Center
Nursing Home
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Does this person take medication on a daily basis? If so, how many?
N/A
1-2 medications daily
3-5 medications daily
6+ medications daily
Unsure
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Has this person fallen in the last three (3) months?
Yes
No
Don't Know
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Please rate the importance of the following activities for this person:
Very Important
Somewhat Important
Not Important
Attending religious service/church
Participating in social clubs/activities
Participating in physical activities/exercise
Going out to eat
Going out to shop
Driving
How did you hear about Concierge Care Advisors?
Phone Number
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Area Code
Phone Number
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