Is Home Health Care Beneficial? 1. Have you or a loved one been diagnosed with one of the below conditions? Stroke Diabetes Heart Condition (Heart Failure) Respiratory condition (COPD) Dementia, Alzheimer's, Confusion Cancer Ohter 2. Have you or a loved one received a terminal diagnosis with 6 months or less? Yes No Unsure 3. Have you or a loved one experiences any of the below in the previous 3 months? Serious Illness Joint Replacement Amputation Loss of balance, falling or dizziness Depression Trouble eating / swallowing 4. Are you or a loved one currently taking any of the below medications or treatments? Oxygen Dialysis Pain Medication Diabetic medication IV medication Blood Thinning / anti clot medication 5. Do you or a loved one have trouble tracking which medicines to take or incorrectly taken the wrong one / dosage? Yes No 6. Do you or a loved on have difficulty performing any of the below daily tasks?Dressing, preparing meals, bathing, using the restroom, shopping or driving. Yes No 7. How frequent are visits or calls to the doctor to manage symptoms or side-effects from medication?? Several times a month Once a month A few times a year Once a year or less Unsure 8. Select the best option that describes the difficulty when leaving home No difficulty Some difficulty Require support to leave home (walker, wheelchair) Once a year or less Unsure First Name(Required) Last Name(Required) Email Address(Required) Phone Preferred Contact Method(Required)EmailPhone Call Δ
