Home Health Care Assessment Form

Home Health Care Assessment

Home Town Healthcare is here to provide answers, support, and skilled nursing services for your loved one. Take our brief survey to determine if your loved one would benefit from our in-home skilled nursing services and let us help you navigate the challenges of home health care and caregiving with compassion and expertise. We are committed to keeping your contact information confidential. We do not sell, rent, or lease our contact data or lists to third parties, and we will not provide your personal information to any third party individual, government agency, or company at any time.

Question 1 – Have you or your loved one been diagnosed with any of these conditions?
Question 2 – Have they experienced any of the following in the past 3 months?
Question 3 – Has your loved one been diagnosed with a terminal condition, with six months or less life expectancy?
Question 4 – Has their doctor prescribed any of the following medications or treatments?
Question 5 – Does your loved one have trouble keeping track of which medications they’re supposed to take, or have they accidentally taken the wrong medication or dosage?
Question 6 – Do they have difficulty performing any of the following tasks?
Question 7 – How often do they visit or call the doctor to deal with symptoms of their condition or side-effects from medication?
Question 8 – How difficult is it for your loved one to leave home? Please select the option that best describes their current situation.
Question 9 – How do you or your loved one plan to pay for care? (Select all that apply)