Needs Assessment

Please select if you have been diagnosed with any of the following medical conditions.

Heart failure or other heart condition

Stroke

Diabetes

COPD or other respiratory condition

Dementia or neurological condition

Cancer

Other

Has a doctor prescribed any of the following medications or treatments?

Anti-clotting or blood thinning medication

Diabetic medication or treatment

Pain Medication

IV Medication

Dialysis

Oxygen

Other

Has any of the following health events happened in the past 3 months?

Serious illness (pneumonia, infection, flu)

Joint replacement or surgery (knee, hip, shoulder, etc.)

Trouble eating or swallowing

Falls, dizziness or loss of balance

Depression

Amputation

Is there any difficulty performing any of the following tasks?

Bathing

Getting dressed

Preparing food

Using the restroom

Grocery Shopping

Driving

How frequent is a doctor contacted to deal with symptoms of current conditions or side-effects from medication?

Are there any issues struggling with medication management or taking incorrect medications/doses?

How often is it difficult to leave home?

Have disease-directed treatments, like chemotherapy, dialysis or multiple hospitalizations from a chronic disease, become less effective?

What is the primary focus when it comes to a treatment plan?

Have you or your loved one been diagnosed with a terminal condition, with six months or less life expectancy?

Please select current insurance.

Medicare

Medicaid

Private Insurance

Veterans Administration (VA) Benefits

None/Other