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These questions are intended to be a guide to help you evaluate your service needs. In the coming months, the answers you provide to these questions will be analyzed by the system and lead to recommendations for specific service types and providers.

1.
For whom are you seeking care?

Self

Spouse

Child

Other relative

Parent

Friend/other

2.
Where would she or he prefer to receive care?

At home (know for certain it's possible to remain at home)

Would like to remain at home, but don't know for certain if it's possible

At a residential facility

Not sure

3.
Which tasks does this person need assistance with?

Eating

Toileting

Dressing/Grooming

Bathing

Transferring (from bed into a wheelchair, for example)

Medication reminders or supervision

4.
Does he or she need help with household chores?

Cooking

Telephone calls

Shopping

Heavy cleaning

Money management

Light cleaning

Transportation

5.
How mobile is this person?

Walks without assistance

In a wheelchair

Needs assistance to walk

Immobile

6.
Does the person exhibit any of these behaviors?

Confusion about where he or she is

Verbal or physical aggression

Forgets the names of close family members or friends

Wanders away from home

7.
Is he or she in any of the following situations?

Regularly left alone for more than 24 hours

Inadequate opportunities to socialize with others

Care needs often unmet

Family or friends don't live close enough to help or visit on a regular basis

8.
Is the person able to pay for services out of pocket?

Entirely

Not at all

Somewhat

Don't know

9.
Does she or he qualify for financial assistance?

Veterans' Administration

Long-term care insurance

Medicaid

Other

Medicare

10.
Why does this person need long-term care?

Recovering from an injury or illness (an auto accident, a broken bone etc.)

Has a long-term or chronic condition

11.
Which medical conditions does the person have?

Alzheimer's or Dementia

Diabetes

Brain injury

Parkinson's Disease

Cancer

Multiple Sclerosis

Stroke

Developmental disablility

Spinal cord injury

Kidney disease

Other neurologic or sensory problems

Other metabolic or endocrine problems

Pulmonary (lung) disease

HIV/AIDS

Heart problems

Arthritis

Other circulatory problems

Other musculoskeletal problems

Recovering from surgery infections or injuries

Depression

Psychiatric

12.
What are his / her 2 or 3 major needs?

Daily living assistance

Transportation

Skilled nursing care

Companionship

Rehabilitation from surgery, an accident or stroke, etc.)

Support in dying (in the last stages of illness)

Social and recreational activities

Management of overall care needs

Develop a care plan

Care in case of emergency

13. Which of these other services might be useful for this person or her/his family?

Legal advice or estate planning

Support resources for caregivers

Long-term care insurance

Professional care manager

Professional medication assessment

Medication and appointment reminders

14. What is the person's age?

Age

1.	For whom are you seeking care?
	Self	Spouse
	Child	Other relative
	Parent	Friend/other
2.	Where would she or he prefer to receive care?
	At home (know for certain it's possible to remain at home)	Would like to remain at home, but don't know for certain if it's possible
	At a residential facility	Not sure
3.	Which tasks does this person need assistance with?
	Eating	Toileting
	Dressing/Grooming	Bathing
	Transferring (from bed into a wheelchair, for example)	Medication reminders or supervision
4.	Does he or she need help with household chores?
	Cooking	Telephone calls
	Shopping	Heavy cleaning
	Money management	Light cleaning
	Transportation
5.	How mobile is this person?
	Walks without assistance	In a wheelchair
	Needs assistance to walk	Immobile
6.	Does the person exhibit any of these behaviors?
	Confusion about where he or she is	Verbal or physical aggression
	Forgets the names of close family members or friends	Wanders away from home
7.	Is he or she in any of the following situations?
	Regularly left alone for more than 24 hours	Inadequate opportunities to socialize with others
	Care needs often unmet	Family or friends don't live close enough to help or visit on a regular basis
8.	Is the person able to pay for services out of pocket?
	Entirely	Not at all
	Somewhat	Don't know
9.	Does she or he qualify for financial assistance?
	Veterans' Administration	Long-term care insurance
	Medicaid	Other
	Medicare
10.	Why does this person need long-term care?
	Recovering from an injury or illness (an auto accident, a broken bone etc.)	Has a long-term or chronic condition
11.	Which medical conditions does the person have?
	Alzheimer's or Dementia	Diabetes
	Brain injury	Parkinson's Disease
	Cancer	Multiple Sclerosis
	Stroke	Developmental disablility
	Spinal cord injury	Kidney disease
	Other neurologic or sensory problems	Other metabolic or endocrine problems
	Pulmonary (lung) disease	HIV/AIDS
	Heart problems	Arthritis
	Other circulatory problems	Other musculoskeletal problems
	Recovering from surgery infections or injuries	Depression
		Psychiatric
12.	What are his / her 2 or 3 major needs?
	Daily living assistance	Transportation
	Skilled nursing care	Companionship
	Rehabilitation from surgery, an accident or stroke, etc.)	Support in dying (in the last stages of illness)
	Social and recreational activities	Management of overall care needs
	Develop a care plan	Care in case of emergency
13.	Which of these other services might be useful for this person or her/his family?
	Legal advice or estate planning	Support resources for caregivers
	Long-term care insurance	Professional care manager
	Professional medication assessment	Medication and appointment reminders
14.	What is the person's age?
Age