Enchantment Assisted Living Survey
I am taking this Care Questionnaire for?
Myself
My Parent
My Spouse
A Patient
Someone Else
Does your loved one require in-home support 24 hours a day?
Yes
No
Maybe
Is your loved one experiencing any of the following? (Check all that apply or if none, click next)
Trouble Hearing/Hearing Loss
Low Vision/Difficulty Seeing
Difficulty Walking
Difficulty Eating
Depression
Falling
Has your loved one stayed in any of the following in last 6 months? Is your loved one experiencing any of the following? (Check all that apply or if none, click next)
Hospital
Rehab/Skilled Nursing Facility
Assisted Living Facility
In-patient Stay
Does your loved one need someone to help them with any of the following? (Check all that apply or if none, click next)
Getting Dressed
Bathing
Using the Bathroom
Preparing Meals
Taking Medications
Getting to the Doctor's Office
Is your loved one having difficulty remembering things such as paying their bills each monrh?
Yes
No
Maybe
Has your loved one ever been diagnosed dementia or Alzheimer's?
Yes
No
Maybe
Has your loved one ever wandered or driven away from a known location and felt disoriented or lost?
Yes
No
Maybe
Great! You Qualify Assisted Living. Please fill out the form below if you would like to Schedule a Tour. Thank you
First Name
Last Name
Email
*
Phone
*
