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info@comfortkeeperstt.com

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Comfort Careers

We’re as dedicated to our team members as we are
to our residents. Learn more about working at Comfort Keepers.

© 2020 Comfort Keepers Assisted Living

What type of care do you need?

Take our 2-minute Care Questionnaire to help determine which type of care may be the best option for you or your loved one.*

After completing the questionnaire, you can discuss your results with a senior resource counselor and schedule a full assessment† to discover if Comfort Keepers is right for you.

Let's Get Started

I am taking this Care Questionnaire for:

Myself
My Parent
My Spouse
A Patient
Someone Else

Are you experiencing any of the following?
(Check all that apply or if none, click next)

Trouble Hearing/Hearing Loss

Low Vision/Difficulty Seeing

Difficulty Walking

Difficulty Eating

Depression

Falling or Unsteadiness

Next Back

Have you stayed in any of the following in the last 6 months?
(Check all that apply or if none, click next)

Hospital

Rehab/Skilled Nursing Facility

Assisted Living Facility

In-Patient Stay

Next Back

Are you still under a doctor's prescribed regime/care plan?

Yes
No

Back

Do you need someone to help you with any of the following?
(Check all that apply or if none, click next)

Getting Dressed

Bathing

Using the Bathroom

Preparing Meals

Taking Medications

Getting to the Doctor's Office

Next Back

Do you have difficulty remembering things such as paying your bills each month?

Yes
No

Back

Have you ever been diagnosed with dementia or Alzheimer's?

Yes
No

Back

Have you ever wandered or driven away from a known location and felt disoriented or lost?

Yes
No

Back

Do you have additional information to share? (Optional): Get Results Back

Does your loved one require in-home support 24 hours a day?

Yes
No

Back

Is your loved one experiencing any of the following?
(Check all that apply or if none, click next)

Trouble Hearing/Hearing Loss

Low Vision/Difficulty Seeing

Difficulty Walking

Difficulty Eating

Depression

Falling

Next Back

Has your loved one stayed in any of the following in the last 6 months?
(Check all that apply or if none, click next)

Hospital

Rehab/Skilled Nursing Facility

Assisted Living Facility

In-Patient Stay

Next Back

Are they still under a doctor's prescribed regime/care plan?

Yes
No

Back

Does your loved one need someone to help them with any of the following?
(Check all that apply or if none, click next)

Getting Dressed

Bathing

Using the Bathroom

Preparing Meals

Taking Medications

Getting to the Doctor's Office

Next Back

Is your loved one having difficulty remembering things such as paying their bills each month?

Yes
No

Back

Has your loved one ever been diagnosed with dementia or Alzheimer's?

Yes
No

Back

Has your loved one ever wandered or driven away from a known location and felt disoriented or lost?

Yes
No

Back

Do you have additional information to share? (Optional): Get Results Back

Get In Touch

Speak with a senior resource counselor to discuss your results or request a full assessment.†

Contact Us

Find A Community

Search for a nearby community that offers the care you may need.

Save Your Results

Print or email your Care Questionnaire results.

Email your Care Questionnaire results.

Contact us to discuss your results or request a full assessment†

Fields marked with an asterisk (*) are required.

* * * * *

Choose Your Community

Choose Your Community

I give permission for my care questionnaire results to be shared with a senior living counselor.

Back to Results

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Thank You!

Our counselor will be in contact to discuss your results, schedule a tour, or schedule a full assessment.

* The Care Questionnaire results are not a physician's diagnosis, nor is it an assessment by a licensed professional. To validate your Care Questionnaire results, you will need to speak with a Comfort Keepers senior living counselor to schedule a full assessment and determine if Comfort Keepers can provide the care that you need. Certain states also require a physician assessment prior to moving into a community.

† During the Comfort Keepers assessment, you will meet with members of the Comfort Keepers team to determine if you or your loved one’s needs may be met in one of our communities, and if so, what care level may be appropriate. The assessment is not a healthcare evaluation, and the results are the property of Comfort Keepers.

Are you sure you would like to exit this Care Questionnaire?

Yes No

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