What health concerns do you have about your loved one? Select all that apply.
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Mobility
Memory Related Issues
Recent Illness or Injury
Overall Decline
Safety
What social concerns do you have about them?
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Loneliness
Recent loss of friends/significant other
Things to do
Emotional connection
Not driving/transportation
What care-needs concerns do you have?
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Personal care
Medication care
General safety
Ambulation
Not driving
Do you have any home maintenance/downsizing concerns?
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Inside maintenance/cleaning, repairs
Exterior maintenance/lawncare
Too much stuff/unneeded space
Are they experiencing any loneliness due to any of these reasons?
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Loss of companion
Loss of friends
Loss of family
Loss of spouse
On a scale of 1-10, how ready are you to consider change? (1 is not at all ready. 10 is very ready)
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What interests do they have?
Travel
Sports
Music
History
Collections
Art
Games
Trivia
Family
Reading
Television
Movies
What career did they/do they have?
What are their favorite foods?
What kind of music do they like?
What is their favorite book and/or movie?
What keeps you up at night?
How financially ready are you to consider change? (1 is not at all ready. 10 is very ready)
What is your first name?
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What is your last name?
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What is your mobile phone?
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What is your email address?
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