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 about them?
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Personal care
Medication care
General safety
Ambulation
Not driving
Do you have any home maintenance/downsizing concerns about your loved one?
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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 they 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 them up at night? Or what keeps you up at night?
How financially ready are they 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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