This client questionnaire is designed to help us understand your needs and desires as much as possible -- so we can match you with the best senior living options that are perfect for you!

This is a somewhat lengthy questionnaire, so feel free to skip as much as you'd like.

 
First Name *
Last Name *
Spouse's First Name
Spouse's Last Name
Phone # *
E-mail Address
Street Address
City
State
Zip Code
Your age
Spouse's age

Let us know about your physical and medical needs:

Check which "activities of daily living" you may need help with (check as many as you want):
Bathing
Dressing
Transferring (in and out of bed, chair, etc.)
Walking
Using the toilet
Eating
Medication management
Which type(s) of accommodation are you interested in?







Please check all activities you (or your spouse) may be interested in:
Art
Bible study
Bingo
Board games
Bridge
Card games
Casino
Chair yoga
Church
Cooking
Cornhole
Dancing
Field trips
Fitness classes
Gardening
Golf putting
Gym
Hair salon
Happy hour
Jacuzzi
Lectures
Live musical performances
Mah Jongg
Movies
Nails (mani, pedi)
Paint and sip
Pool (billiards)
Reading
Scrabble
Shopping
Spa (massage, etc.)
Swimming
Synagogue
Therapeutic whirlpool2
Walking
Water aerobics
Other (please specify)

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