Care Recipient
Survey: |
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(Please check all that apply) |
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For whom are you interested in
getting information regarding
eldercare products and services? |
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(Please select
one) |
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Please provide
the following information about
the care recipient. |
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When would you like services to
begin? |
(Please
select one) |
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Please indicate the number of
hours of support services that
you estimate the care recipient
requires. |
(Please select one) |
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Which of the following best
describes the care recipient's
current living arrangement? |
(Please select one) |
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How would you
describe the care recipient's
feelings about receiving
assistance? |
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What, if any, existing medical conditions does the care recipient have? |
(select all that apply) |
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