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Where are you currently living? Homefamily or friends's homeAssisted Living FacilityOther
Were you recently discharge from a hospital or facility and need nursing, therapy, or aid care at home? YesNo
Do you need help with setting up and organizing and medications? YesNo
Does it currently to take a lot of effort to move around in your home? YesNo
Have you experienced an increase in forgetfulness over the last few months? YesNo
Do you have difficulty in performing activities of daily living, such as grooming, bathing, cleaning? YesNo
Do you currently have a physician? YesNo
What type of insurance do you have? MedicareMedicaidCommunity Health ChoicesPrivate insuranceMultipleNone
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