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Questionnaire
First name
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Last name
*
Date of Birth
*
Email
*
Phone
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Can you or your family member climb stairs without assistance?
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Yes
No
Are you or your family comfortable living in a household with young children (including sharing common spaces)? Family room, Dinning room etc.
*
Yes
No
Do you or your family member have any current health conditions we should be aware of (for safety and support purposes)?
*
Yes
No
Are you or your family willing to complete a AHCA 3110 Health Assessment form.
*
Yes
No
Do you or your family member have any special dietary restrictions or allergies?
*
Yes
No
Do you or your family member require assistance with daily living activities (such as bathing, dressing, or meal preparation)?
*
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