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Home Health Care Assessment Quiz

Could Home Health Care Help?

If you’re an adult caring for your mom, dad or other family member with health care challenges, you’re not alone. Today in the United States, more than one in three Americans find themselves in the same position. It can be overwhelming for the entire family – especially if you don’t know where to turn for answers and support.

This quiz will create a personalized report to help you understand the risk factors for your mom, dad or loved one and if home health care may be able to help.

Question 1

Has your mom, dad or loved one been diagnosed with any of these conditions?

Heart failure or other heart condition
Stroke
Diabetes
COPD or other respiratory condition
Alzheimer’s/Dementia/Confusion
Cancer
Other

Question 2

Have they experienced any of the following in the past 3 months?

Serious illness (pneumonia, infection, flu)
Joint replacement or surgery (knee, hip, shoulder, etc.)
Falls, dizziness or loss of balance
Trouble eating or swallowing
Depression
Amputation

Question 3

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

This question is required.

Question 4

Has their 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

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?

Frequently – Several times a month
Regularly – At least once a month
Sometimes – A few times a year
Rarely – Once a year or less
Don't know

Question 6

Do they have difficulty performing any of the following tasks?

Bathing
Getting dressed
Preparing food
Using the restroom
Grocery Shopping
Driving

Question 7

How often do they visit or call the doctor to deal with symptoms of their condition or side-effects from medication?

Frequently – Several times a month
Regularly – At least once a month
Sometimes – A few times a year
Rarely – Once a year or less
Don't know

Question 8

How difficult is it for your loved one to leave home? Please select the option that best describes their current situation.

They’re at high risk of severe illness from COVID-19 (age 65+ or any age with an underlying condition).
Their condition makes it very difficult or impossible to even leave bed.
Leaving home requires a lot of effort that exhausts them. They leave home infrequently and briefly because of the difficulty.
They use a walker, wheelchair, or require another person’s help to leave home.
They have some difficulty leaving home, but not enough to stop them from going somewhere.
They have no difficulty leaving home.

Question 9

What is the ZIP Code where your mom, dad or loved one lives? (required)

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