Question 1

Has your mom, dad or loved one been diagnosed with any of these conditions?

Heart failure or other heart condition

Stroke

Diabetes

COPD or other respiratory condition

Alzheimer’s/Dementia/Confusion

Cancer

Other

Question 2

Have they experienced any of the following in the past 3 months?

Serious illness (pneumonia, infection, flu)

Joint replacement or surgery (knee, hip, shoulder, etc.)

Falls, dizziness or loss of balance

Trouble eating or swallowing

Depression

Amputation

Question 3

Has your loved one been diagnosed with a terminal condition, with six months or less life expectancy?

YES

NOT SURE

NO

Question 4

Has their doctor prescribed any of the following medications or treatments?

Anti-clotting or blood thinning medication

Diabetic medication or treatment

Pain Medication

IV Medication

Dialysis

Oxygen

Other

Question 5

Does your loved one have trouble keeping track of which medications they’re supposed to take, or have they accidentally taken the wrong medication or dosage?

Frequently – Several times a month

Regularly – At least once a month

Sometimes – A few times a year

Rarely – Once a year or less

Don't know

Question 6

Do they have difficulty performing any of the following tasks?

Bathing

Getting dressed

Preparing food

Using the restroom

Grocery Shopping

Driving

Question 7

How often do they visit or call the doctor to deal with symptoms of their condition or side-effects from medication?

Frequently – Several times a month

Regularly – At least once a month

Sometimes – A few times a year

Rarely – Once a year or less

Don't know

Question 8

How difficult is it for your loved one to leave home? Please select the option that best describes their current situation.

They’re at high risk of severe illness from COVID-19 (age 65+ or any age with an underlying condition).

Their condition makes it very difficult or impossible to even leave bed.

Leaving home requires a lot of effort that exhausts them. They leave home infrequently and briefly because of the difficulty.

They use a walker, wheelchair, or require another person’s help to leave home.

They have some difficulty leaving home, but not enough to stop them from going somewhere.

They have no difficulty leaving home.