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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?
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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:
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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:
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Currently residing at:
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How soon will a move be needed?
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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?:
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Any additional questions/comments:
Submit
*Missing Required Field(s).
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