NEED OUR HELP? We can help.

Please complete the information and survey below and we will contact you.

* = Required Field
* First Name:
* Last Name:
* Company Name:
* Email Address:
* Address:
* City:
* State:
* Zip Code:
* Telephone: ( )

How To Know if You Need Help
Click Here for Scoring Interpretation

1. Does your family member miss meals?    Yes     No    Maybe
   Due to forgetfulness?    Yes     No    Maybe
   Has difficulty using hands/arms?    Yes     No    Maybe
   Has a swallowing problem?    Yes     No    Maybe
2. Is your family member unable to evacuate home in case of an emergency?    Yes     No    Maybe
   Due to limited capability?    Yes     No    Maybe
   Due to mental capability?    Yes     No    Maybe
3. Is your family member unable to get in and out of a chair and/or bed alone?    Yes     No    Maybe
   Due to limited capability?    Yes     No    Maybe
   Due to mental capability?    Yes     No    Maybe
4. Is your family member unable to use the commode alone?    Yes     No    Maybe
   Due to limited capability?    Yes     No    Maybe
   Due to mental capability?    Yes     No    Maybe
5. Is your family member unable to groom hair and self?    Yes     No    Maybe
   Due to limited capability?    Yes     No    Maybe
   Due to mental capability?    Yes     No    Maybe
* Additional Comments:
     
    Copyright 2005 Health Companions, Inc. All Rights Reserved.