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Begin your loved one's assessment to:

Find the right care for them
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Schedule tours for places that might be a fit

Interests and activities - check all that apply

Bingo / Cards / Group Games

Exercise / Fitness

Religious / Spiritual

Special Diet

TV / Movies

Golf

Knitting

Pets

Gardening

Independence and mobility - check all that apply

Walks

Drives

Lives alone

Lives alone with home care

Lives with family or in group home

Lives in assisted living

Lives in retirement community

Needs daily assistance with self-care

Needs daily assistance with medication management

Needs occasional assistance

Experiences occasional memory loss

Experiences severe memory loss

Health and medical conditions - check all that apply

Dementia

Cancer

Diabetes

Stroke

Blind

Arthritis

Obesity

Dialysis

Bed Ridden

Handicapped

Heart Disease

Physical Therapy

Alzheimer's Disease

Parkinson's Disease

Terminally Ill

Currently Hospitalized

Hospitalized in Last 6 Months

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Last Name *

E-mail *

Phone *

Referred by *

Location *

Desired Care *

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About A Place for Mom

Helping families find senior housing and senior care since 2000.
Trusted advisors to more than 200,000 families each year.

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Copyright © 2000-2012 A Place for Mom, Inc. All rights reserved. A Place for Mom is the nation's largest senior living referral information service. We are paid by our participating communities and providers, therefore this service is offered at no charge to families. APlaceforMom.com complies with the Can-Spam Act of 2003. 1300 Dexter Avenue North, Suite 400, Seattle, WA 98109

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