Elderday Adult Day Health Care Online Inquiry
* Required
This inquiry is for:
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Myself
Someone else
Name of person completing this form
*
Your Phone
*
Your Email
Relationship to Potential Elderday Participant
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Name of Potential Elderday Participant
*
Date of Birth
MM slash DD slash YYYY
Cell Phone
Home Phone
Email
Preferred Language
Please select one:
English
Spanish
Other
List your preferred language
Street Address
*
City
*
State
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ZIP Code
*
Primary Care Doctor's Name
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Doctor's Phone
Doctor's Fax
Name of Medical Insurance
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Medi-Cal or Medical Record Number
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Elderday provides day health care for adults with some of the following types of medical conditions. Do any of these apply to the potential participant?
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Diabetes
Alzheimer’s Disease or other dementia (severe memory loss)
Heart disease (atrial fibrillation, congestive heart failure, etc.)
Brain injury – from stroke, accident, or any other reason
Parkinson’s Disease
Multiple Sclerosis
Long term stable mental health condition
Developmental disability (Regional Center client)
Other
Please list other types of medical conditions not listed above.
*
Has the potential participant been in the hospital or gone to the emergency room in the last several months?
Yes
No
Has the potential participant had any falls or injuries in the last several months?
Yes
No
Does the potential participant have difficulty with any of the following activities?
Walking
Bathing
Dressing
Eating
Using the toilet
Moving from one place to another (like sitting to standing or in bed to standing)
Preparing meals
Managing medications
Managing money
Accessing community resources
Who should Elderday staff contact regarding this inquiry?
Person named above completing this form
Potential participant
Other person
Relationship
Contact for this person
How did you hear about Elderday?
CAPTCHA
Click the SEND button only once. It may take a few seconds for the form to be submitted. You will see a confirmation message when the form has been received.
Email
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