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p2.jpgElder Care and Transitions Consulting, LLC
8007 Mullen Road
Lenexa, KS 66215
Phone: 913-825-0181
Fax: 913-825-0182
E-mail:  info@ElderCareTransitions.com

 Signs of Aging Questionnaire

To help us help you evaluate your situation, please complete the following form and click Submit. Or send us an email at info@ElderCareTransitions.com.  We will contact you as soon as possible regarding your care needs.  Be assured that your information will be held in the strictest confidence.

Have you observed any of the following?

1. Poor or declining physical health
Yes    No   
7. Chronic pain
Yes    No   
2. Inability to bath, eat, walk, take medication, and perform other day-to-day functions independently
Yes    No   
8. Substance abuse
Yes    No   
3. Depression and/or loneliness
Yes    No   
9. Difficulty coordinating or monitoring different prescribed medications
Yes    No   
4. Falling in the home and general lack of safety when alone
Yes    No   
10. Inability to pay for health care or long-term care that may be needed
Yes    No   
5. Forgetfulness and/or absentmindedness
Yes    No   
11. Unclear documentation of last will and wishes
Yes    No   
6. Weight loss and/or lack of balanced nutritional meals
Yes    No   
12. High levels of caregiver stress
Yes    No   
13. Desire for alternative living arrangements
Yes    No   
We appreciate your interest. How would you like us to contact you?
Your Name
Your relationship to care recipient
Care recipient    Care recipient's spouse    Other caregiver   
Your telephone number
Your email address *

* Required to submit this form





Elder Care and Transitions Consulting, LLC
8007 Mullen Road
Lenexa, KS 66215 

Phone: 913-825-0181
Fax: 913-825-0182
E-mail:  info@ElderCareTransitions.com

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