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Questionnaire Form
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Home
About Us
Testimonials
Volunteer
Questionnaire Form
Contact Us
Questionnaire Form
What’s Important To You,
Is Important To Us
At Autumn Meadows Assisted Living, we create residences with care, comfort, and a deep respect for heritage as our core values. Please fill out the form below to join our waiting list.
Waitlist Form Page
Name
First
Last
Email
Phone
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Other
Payment
Private Pay
Medicaid/Medicare
Long-term care insurance
Language
English
or/and
Other
Your spoken language
Please check the box that most accurately describes your current needs.
Activities of Daily Living
Mobility:
Independently
With supervision, or stand-by, or cuing/coaching
One-person physical assistance
Two-person physical assistance, or needs complete mechanical assistance (e.g., Hoyer Lift)
Eats:
Independently
With supervision, or set-up, or cuing/coaching
With physical Assistance or using of adaptive devices, such as built-up utensil, plate guard, or Geri-Cup, to feed self
Must be fed or needs tube feeding
Transfer to Bed, Chair, or Toilet:
Independently (or with assistive device)
With supervision, or stand-by or set-up, or cuing/coaching
One-person physical assistance
Two-person physical assistance, needs complete assistance
Bed Mobility: (how one move to and from laying position, turns side to side, and positions body while in bed)
Independently (or with assistive device)
With supervision, or stand-by or set-up, or cuing/coaching
One-person physical assistance
Two-person physical assistance, needs complete assistance
Use of stairs:
Independently (or with assistive device)
With supervision, or stand-by, or cuing/coaching
One-person physical assistance
Two-person physical assistance, or unable to use stairs
Restroom:
Independently
With supervision, or stand-by or set-up, or cuing/coaching
Needs physical assistance from one other person
Incontinent, needs complete assistance
Completes Bathing:
Independently
With supervision, or stand-by or set-up or cuing/coaching
Needs physical assistance (e.g., help in or out of tub, washing hair)
Must be bathed, needs complete assistance or mechanical assistance (e.g, Hoyer Lift)
Completes Grooming: (teeth, make-up, shaving, hair)
Independently
With supervision, or stand-by or setup, or cuing/coaching
Needs physical assistance
Must be groomed, needs complete assistance