NRIs! Want to know about Your Parents capability without You? -

How would you evaluate your parents overall health. Would you say your parents are: *

In good physical health. (No significant illnesses or disabilities. Only routine medical care such as annual checkups required.)
Mildly physically impaired. (You have only minor illnesses and/or disabilities which might benefit from medical treatment or corrective measures.)
Moderately physically impaired. (You have one or more diseases or disabilities which are either painful or which require substantial medical treatment.)
Severely physically impaired. (You have one or more illnesses or disabilities which are either severely painful or life threatening, or which require extensive medical treatment.)
Totally physically impaired. (Confined to bed and requiring full-time medical assistance or nursing care to maintain vital bodily functions.)

What about the amount of social support your Parents receiving from your family, friends, etc? When there have the need to talk to someone or go on outings with friends and/or relatives, do you feel there is someone who fulfills these needs? *

High degree of social support. (Much support is either given or is available, if needed, from family and friends.)
Above average degree of social support. (Given or potentially available from family and friends.)
Average degree of social support from family and friends is given or potentially available.
Below average degree of social support. (While some support is available, it's not consistently available)
No support or potential support is available from either family or friends.

How often does a close friend or relative visit you in your home? *

Several times a week
Weekly
Several times a month
Once a month or less

Which of the following best describes your parents capacities to perform everyday activities: *

Can perform all physical activities of daily living without assistance. (Excellent capacity)
Can perform all physical activities without assistance but may need some help with the heavy work such as laundry and housekeeping. (Good capacity)
Regularly require help with certain physical activities and/or heavy work but can get through any single day without help. (Moderate capacity)
Need help each day but not necessarily throughout the day or night. (Severely impaired capacity)
Need help throughout the day and/or night to carry out the activities of daily living. (Completely impaired capacity)

Can your parents get to places out of walking distances: *

Without help
With some help
Completely unable to travel unless special arrangements are made

Can your parents do there own housework: *

Without help
With some help
Completely unable to do any housework

Can your parents go shopping for groceries: *

Without help
With some help
Completely unable to do any shopping

Can your parents prepare own meals? *

Without help
With some help
Completely unable to prepare any meals

Can your parents do own laundry? *

Without help
With some help
Completely unable to do any laundry at all

Can your parents take care of own appearance, things like combing your hair, shaving, etc? *

Without help
With some help
Someone does all these types of things for you

Can there dress and undress by themself? *

Without help (pick out clothes, dress/undress self)
With some help
Does someone dress and undress(Completely Unable)

In the past 3 Months, how many different kinds of treatments have there taken?

In the past 24 hours, how many different kinds of medication have there taken?

If your parents have taken medication in the last 24 hours: *

Without help (in the right doses at the right time)
With some help (take medicine if someone prepares for them and/or reminds to take it)
Completely unable to take own medicines

Age category of your parents: *

On a scale of 1-5 how comfortable to take parent care services for your parents? *

Name *

First

Last

Email *

Phone Number: *

Your location: *