1. Does your loved one require assistance with mobility?
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Yes, they need assistance with walking, transfers, or getting in and out of chairs.
No, they are fully mobile without assistance.
2. Does your loved one require assistance with personal hygiene tasks?
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Yes, they need help with bathing, dressing, or toileting.
No, they can manage personal hygiene independently.
3. How important is it for your loved one to have emotional support from their caregiver?
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Extremely important
Moderately important
Somewhat important
Not important
4. Would your loved one benefit from companionship during the day?
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Yes, they would enjoy social interaction and companionship.
No, they prefer solitude or have ample social support.
5. How Would You Describe Your Loved One's Current Level Of Independence?
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Fully independent
Somewhat independent, but needs occasional assistance
Requires significant assistance with daily tasks
Fully dependent on assistance for most tasks
6. What type of care services are you primarily seeking?
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Companionship and emotional support
Personal hygiene assistance
Dementia care
Assistance with mobility and transfers
Other
7. How would you rate your loved one's overall health condition?
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Excellent
Good
Fair
Poor
8. What activities does your loved one enjoy participating in?
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Going for walks or outings
Engaging in hobbies or interests
Socializing with friends or family
Attending community events or gatherings
Other
9. How important is it for your loved one to maintain their independence?
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Extremely important
Moderately important
Somewhat important
Not important
First Name
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Last Name
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Phone
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Email
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