Who Needs Care?
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Who Needs Care?
Daughter
Son
Spouse
Other Relative
Neighbor/Friend
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How Old is the Person Who Needs Care?
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How Old is the Person Who Needs Care?
45-54
55-64
65-74
75-84
85 or older
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Male or Female?
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Male or Female?
Male
Female
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What is their current living situation?
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What is their current living situation?
Living Alone at Home
Living at Home with Family
In the Hospital
In the Hospital Discharging to Home
Assisted Living
Independent Senior Living
Nursing Home
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Estimate How Much Care They Might Need
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Estimate How Much Care They Might Need
A few hours per week
More than 20 hours per week
40 or more hours per week
Around-the-Clock Care
Live-In Care
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What Type of Care is Needed? (Check all that apply)
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What Type of Care is Needed? (Check all that apply)
Bathing/Showering and grooming assistance
Toileting and incontinence care
Medication reminders
Light meal preparation
Errands/Shopping/Pharmacy
Light housekeeping
Light laundry
Companionship
Companion Transportation to Medical Appointments
Hospice Care
Respite Care
Alzheimer’s and dementia care
Snow Removal
Lawn Care
Other
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How will care be paid for?
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How will care be paid for?
Private Funds
Alberta Health Services (AHS)/Alberta Blue Cross; WCB
Private Insurance
Veterans Benefits
Other
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First Name
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Last Name
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Email
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Phone
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Postal Code
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I agree/authorize/consent
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I Agree/Authorize/Consent
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