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Caregiver Baseline

"*" indicates required fields

The Agency on Aging Area 4 team will utilize this questionnaire to establish the pilot program baseline data for Care 4 Caregivers. The Case Manager will complete the below questions via a facilitated discussion with the caregiver. An asterisk next to the question indicates that the question is required to be answered. Case Managers can reassure the caregiver that their responses will be kept confidential and will not be shared nor associated with their personal identifying information.  
Caregiver Name:*
During the past week, have you had severe fatigue or exhaustion?*
How often do you feel that you lack companionship?*
How often do you feel left out?*
How often do you feel isolated from others?*
How many times did you go to an emergency room that did not result in hospitalization in the past three months?*
How many times did you stay in a hospital overnight or longer in the past three months?*
Questions regarding the person cared for:
Does your loved one live alone?*
How often does your loved one see or talk to people she/he cares about and feels close to within the last 3 months?*
Has your loved one fallen in the past 3 months?*
Do you think your loved one may fall in the next 3 months?*
Terms and Conditions*
The Telephone Consumer Protection Act generally requires us to obtain consent before contacting people on their mobile phones. By enrolling in this program, you are granting consent to GoMo Health to contact you via text message to the number you are enrolling with from the number 43386. You may get up to 12 messages per week. Please note that depending on your mobile phone service plan, message and data rates may apply according to your mobile provider. You also confirm that you are the wireless subscriber or owner of the mobile number provided and have the authority to provide consent. For help, please text HELP to 43386. You may opt-out at any time by replying STOP or STOPALL to 43386. To unsubscribe from emails, click “unsubscribe” at the bottom of any email you receive. Terms & Conditions can be found at https://c4c.gomohealth.care. GoMo Health Privacy Policy can be found here: https://gomohealth.com/privacy/.

This program is completely voluntary, and you may opt out at any time by replying STOPALL. For assistance with the program, reply HELP. Message and data rates may apply depending on your mobile carrier plan.

Continued use of this site signifies your consent and agreement with these Terms and Conditions.

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