Confirmation (Baseline) - Agency on Aging Area 4 Concierge Care Program

Hidden

Caregiver Name:*

First Name Last Name

Hidden

Cell phone number:*

Hidden

During the past week, have you had severe fatigue or exhaustion?*

Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
Most or all of the time (5-7 days)

Hidden

How often do you feel that you lack companionship?*

Hidden

How often do you feel left out?*

Hidden

How often do you feel isolated from others?*

Hidden

How many times did you go to an emergency room that did not result in hospitalization in the past three months?*

0
1
2
3+

Hidden

How many times did you stay in a hospital overnight or longer in the past three months?*

0
1
2
3+

Hidden

How many nights in total did the person you care for spend in the hospital?*

Questions regarding the person cared for:

Hidden

Does your loved one live alone?*

Yes
No

Hidden

How often does your loved one see or talk to people she/he cares about and feels close to within the last 3 months?*

Less than once a week
1-2 times a week
3-5 times a week
More than 5 times a week

Hidden

Has your loved one fallen in the past 3 months?*

Yes
No

Hidden

Do you think your loved one may fall in the next 3 months?*

Yes
No

Hidden

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/.

I have fully read and agreed to the terms and conditions of this program.
I have completed the enrollment form, provided electronic consent to enroll, and I grant permission to GoMo Health to contact my cell phone via text message from the phone number 43386.

Hidden

Resource1

Hidden

Resource2

Hidden

Resource3

Hidden

Resource4

Thank You!