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Homebound Assessment
Is Home Health Right For You?
Homebound Assessment
Answer the questions below to get in contact with us and determine whether home health care services could help in your situation.
Has your loved one been diagnosed with any of the following?
Heart failure or other heart condition
Stroke
Diabetes
COPD
Alzheimers/Dementia
Cancer
Other
Has your loved one experienced any of the following in the past 6 months?
Serious illness
Joint replacement/surgery
Falls, dizziness, loss of balance
Trouble eating or swallowing
Depression
Amputation
Has your loved one been diagnosed with a terminal condition, with six months or less life expectancy?
(Required)
Yes
No
Not sure
Has your loved one's doctor prescribed any of the following medications in the past 6 months?
Anti-clotting or blood thinning medication
Diabetic medication or treatment
Pain medication
IV medication
Dialysis
Oxygen
How often does your loved one have trouble keeping track of which medications they’re supposed to take and/or when they are supposed to take them?
Several times a month
At least once a month
A few times a year
Once a year or less
Never
Not sure
Does your loved one have trouble completing any of the following tasks?
Bathing
Getting dressed
Driving
Preparing food
Using the restroom
Grocery shopping
How often does your loved one visit/call the doctor to deal with their symptoms?
Several times a month
At least once a month
A few times a year
Once a year or less
Never
Don't know
Please explain below any difficulties your loved one has in regards to leaving the home (difficult to get out of bed, wheelchair usage, etc.)
(Required)
Name
(Required)
First
Last
Email
(Required)
Zip Code
(Required)
ZIP / Postal Code
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