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Assessment Questionnaire
Type of living needed:
Independent Living
Assisted Living
Memory Care
Board and Care
Ambulatory/Mobility:
No assistance needed
Walker/Cane
Wheelchair
Stand-by assist
Bed ridden
Assistance needed - Check all that apply:
Medication assistance
Meal preparation
Taking showers or baths
Dressing
Assistance with eating
Hygiene assistance
Incontinent Care
Transferring/Assist with walking
N/A
Cognitive Health
Is there any experience of memory loss?
choose an answer...
No memory loss
Sometimes forgetful
Moderate memory loss
Advanced memory loss
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Any issues with wandering?
Yes
No
Check all health conditions that are applicable:
Alzheimer's/Dementia
Parkinson's Disease
Arthritis
Diabetes
Heart Disease
Stroke/TIA
Anxiety
Depression
Cancer
N/A
What is the monthly budget available to cover this care?
Monthly budget:
choose an answer...
Under $1,500
$2,000-$2,500
$2,500-$3,000
$4,000-$5,000
$5,000-$6,000
$6,000 or more
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Any of the following apply:
Veteran
Spouse of Veteran
Long-Term Care Insurance
N/A
Information about the person this search is for:
Name of person(s) needing care:
Age:
2nd person (if applicable):
Age:
Relation to you:
choose an answer...
Self
Spouse
Parent
Relative
Friend
Client
Other
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Currently residing at:
choose an answer...
Home
Home with family
Independent or Assisted Community
Board and Care Home
Skilled Nursing or Rehab Facility
Other
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How soon will a move be needed?
choose an answer...
ASAP
2-4 weeks
1-3 months
3-6 months
1 year +
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Location(s) desired - check all that apply:
Carmel Valley
Chula Vista
Clairemont Mesa
College Area
Coronado
Downtown/Mission Hills/North Park
El Cajon
Escondido
Imperial Beach
La Jolla
La Mesa
Mission Valley
National City
Point Loma
Poway
Rancho Bernardo
Rancho San Diego
Santee
Solana Beach
Other
Additional Info:
Name of person inquiring (if different):
Phone Number:
Email:
Preferred method of communication:
Phone Call
Email
Text Message
How did you hear about us?:
choose an answer...
Healthcare professional
Family or friend
Facebook
Web search
other
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Any additional questions/comments:
Submit
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