We’d like to begin by welcoming you and making sure you’re comfortable before starting. This questionnaire can take some time and requires focus, so we recommend sitting in a quiet, comfortable place where you can concentrate.

You may be wondering what this is all about. The purpose of this questionnaire is to better understand your health, daily functioning, and any limitations you may have. This helps us determine the level of support you may need and where we should focus our assistance when you become a resident.

Your role is simply to choose the answer that best reflects your situation. If there are questions you’re unsure about, that’s perfectly okay — you’ll have the opportunity to clarify or expand on your answers during your in-person assessment.

If you need to take a break, you’re welcome to do so. However, please be sure to click the small save button  at the bottom next to the page count before stepping away. Otherwise, we may need to restart the questionnaire.

Throughout the questionnaire, you’ll notice the word “you” in each question. This may refer either to the individual being assessed or to a surrogate completing the form on their behalf. If a surrogate is answering, responses may be based on their own observations or on information provided by reliable sources, such as close family members.

We appreciate your time and thoughtful responses — they help us provide the best possible care and support.