Arizona Senior Living and Aging Care Agency

Answer each of the following questions where applicable. Once you have completed the survey, click the submit button to receive instant facility recommendations.

Required questions appear in red.

1. Desired location:
State	City

2. What type of accommodations are you interested in? (required):
Alzheimer's Community	Independent Living
Assisted Living Home / Center	Skilled Nursing Care

3. Does the senior primarily use a:
Cane	Wheelchair
Walker

4. Do they require assistance with any of the following? (Check all that apply):
Bathing	Dressing
Eating	Taking medications
Getting in or out of bed	Walking
Toileting

5. Does the senior suffer from any of the following?:
Impaired vision	Hearing deficit
Incontinence (lacks bladder / bowel control)

6. Do they suffer from memory impairment? (required)

No, senior is alert and oriented

Some short-term memory loss

Moderate short-term memory loss with some long-term memory loss

Severe memory loss (diagnosed with Alzheimer's disease / dementia)

7. Does the senior have any of the following dietary needs?:
Diabetic	Low sodium
Low fat / cholesterol	Vegetarian
Soft Foods

8. What type of activities/interests are important to the senior?:
Piano	Bingo
Exercise Class	Gardening
Cooking	Cultural Events
Arts and Crafts	Recreational Outings
Bridge / Playing cards	Billiards / Pool
Daily Walks	Musical Programs
Lectures / Seminars	Religious Activities

9. What type of amenities and services would they like access to?:
Swimming Pool	Transportation Services
Beautician Services	Spa/Whirlpool
Library	Computer and Internet
Cable TV	Physical Therapy
Walking Paths	Massage Therapy

10. What language other than English does the senior require their caregiver to speak?:
Chinese	Italian
Russian	Romanian
Tagalog	French
German	Japanese
Korean	Spanish

11. Would they like to attend church or synagogue services?:
Yes	No

12. Does the senior prefer a room that is: (required)
Private	Semi-private

13. Does the senior desire a facility that:(optional)
Allows pets	Does not allow pets

14. What is your monthly price range? (Choose more than one if desired):
$1,500 to $1,899	$2,700 to $3,099
$1,900 to $2,299	$3,100 to $3,499
$2,300 to $2,699	$3,500+

15. Please enter your contact information (required):
Name
Phone Number: (only digits , no dashes )
Email Address:

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