Aging Registration

Aging Adult DC Counter


Geauga County Department on Aging

Annual Registration
2015 
     
The Geauga County Department on Aging welcomes everyone regardless of race, religion, gender, sexual orientation, gender identity,  national origin, physical or mental disability, or any other basis prohibited by law.


Department on Aging 2015 Online Registration

*  Required
First Name:
 *
Middle Initial:
 *
Last Name:
 *
Date of Birth:
    Calendar *
Gender:
Social Security Number (SSN):
 *
Ethnicity:
Primary Language:
Race:
Marital Status:
Home Address - Street:
 *
Home Address - City:
 *
Home Address - Zip Code:
 *
 Mailing Information - If Different
Mailing Address - Street:
Mailing Address - City:
Mailing Address - Zip Code:
Home Phone Number:
Cell Phone Number:
E-Mail Address:
 In Case of Emergency Information
Primary Physician:
Primary Physician Phone Number:
Alergies:
Medical Conditions:
Medications:
Emergency Contact:
Emergency Contact Relationship:
Emergency Contact Home Phone:
Emergency Contact Cell Phone:
 Residence Information
Primary Residence:
Time at Current Residence:
Living Arrangement:
Number of Persons in Household:
Monthly Income - Individual:
Monthly Income - Married:
Optional Demographics:











 Nutrition Information
Question #1:
Question #2:
Question #3:
Question #4:
Question #5:
Question #6:
Question #7:
Question #8:
Question #9:
Question #10:
Question #11:
 During the past 7 days, how would you rate your ability to perform:
Bathing?:
 excluding washing back and hair
Dressing?:
Toilet Use?:
Transfer?:
Eating?:
Walking in home?:
 During the past 7 days, how would you rate your ability to perform:
Meal Preparation?:
Managing Medications?:
Manage Money?:
Heavy Housework?:
Light Housework?:
Shopping?:
Transportation?:
 During the past 7 days, how would you rate your ability to perform:
Telephone Use?:
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