Who needs care?
Myself
My parent
My spouse
Other family member
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Current living situation?
Living alone
Living with family
Retirement home
Assisted living
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Primary care need?
Select all that apply
Personal care
Companionship
Medication
Meal prep
Mobility
Dementia
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Mobility level?
Fully mobile
Uses walker/cane
Uses wheelchair
Bedridden
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Cognitive status?
No concerns
Mild forgetfulness
Moderate memory issues
Diagnosed dementia
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Safety concerns?
Select all that apply
Falls
Wandering
Medication errors
Isolation
No concerns
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Current caregiver situation?
No caregiver currently
Family providing care (exhausted)
Family providing care (managing okay)
Had paid caregiver (unhappy)
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How urgently do you need care?
Emergency (72h)
Very soon (1 week)
Planning ahead
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Preferred care schedule?
A few hours per week
Several hours daily
24-hour care
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Approximate hours needed per week?
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Biggest concern?
(Optional)
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