Geauga County
Department on Aging
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Aging Registration
Aging Adult DC Counter
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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
First Name:
Middle Name:
Last Name:
Date of Birth:
Month
01 - January
02 - February
03 - March
04 - April
05 - May
06 - June
07 - July
08 - August
09 - September
10 - October
11 - November
12 - December
Date
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
Gender:
Female
Male
Ethnicity:
Other
Hispanic
Primary Language:
English
Other
Race:
Select Your Race
American Indian
Asian
Black / African American
Hawaiian
White
Other
Marital Status:
Select Your Marital Status
Single
Married
Separated
Divorced
Widowed
Other
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:
Allergies:
Medical Conditions:
Medications:
Emergency Contact:
Emergency Contact Relationship:
Emergency Contact Home Phone:
Emergency Contact Cell Phone:
Residence Information
Primary Residence:
Select Your Primary Residence
House / Mobile Home
Private Apartment
Private Apartment in Senior Housing
Assisted Living
Nursing Home
Other
Time at Current Residence:
Select Your Time at Current Residence
Less Then 12 Months
1 - 3 Years
3+ Years
Living Arrangement:
Select Your Living Arrangement
Alone
With Spouse / Partner
With Spouse and Child
With Child / Children
Number of Persons in Household:
Monthly Income - Individual:
Select Your Monthly Income - Individual
$0 - $958
$959 - $1,915
$1,916+
Monthly Income - Married:
Select Your Monthly Income - Married
$0 - $958
$959 - $1,915
$1,916+
Optional Demographics:
Homebound
Disabled
Frail
Holocaust Survivor
LGBT
Limited English Speaking
Medicare Eligible
Neglected - Abused - Exploited
Social Security Eligible
US Citizen
Veteran
Veteran Dependent
Nutrition Information
Question #1:
Yes - I have made changes in lifelong eating habits because of health problems.
No - I have not made changes in lifelong eating habits because of health problems.
Question #2:
Yes - I eat fewer than 2 meals per day.
No - I do not eat fewer than 2 meals per day.
Question #3:
Yes - I eat fewer than nine (9) servings (1/2 cup) of fruits or vegetables every day.
No - I do not eat fewer than nine (9) servings (1/2 cup) of fruits or vegetables every day.
Question #4:
Yes - I eat fewer than two servings of dairy products every day.
No - I do not eat fewer than two servings of dairy products every day.
Question #5:
Yes - I sometimes run out of money to buy food.
No - I do not run out of money to buy food.
Question #6:
Yes - I have a biting, chewing, or swallowing problem that makes it difficult to eat.
No - I do not have a biting, chewing, or swallowing problem that makes it difficult to eat.
Question #7:
Yes - I eat alone most of the time.
No - I do not eat alone most of the time.
Question #8:
Yes - I have lost or gained 10 lbs. in the past 6 months without wanting to.
No - I have not lost or gained 10 lbs. in the past 6 months without wanting to.
Question #9:
Yes - It is sometimes physically difficult to shop, cook, and/or feed myself.
No - It is not sometimes physically difficult to shop, cook, and/or feed myself.
Question #10:
Yes - I have 3 or more drinks of beer, liquor, or wine almost every day.
No - I do not have 3 or more drinks of beer, liquor, or wine almost every day.
Question #11:
Yes - I take 3 or more different prescribed or over-the-counter drugs per day.
No - I do not take 3 or more different prescribed or over-the-counter drugs per day.
During the past 7 days, how would you rate your ability to perform:
Bathing?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
excluding washing back and hair
Dressing?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Toilet Use?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Transfer?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Eating?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Walking in home?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
During the past 7 days, how would you rate your ability to perform:
Meal Preparation?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Managing Medications?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Manage Money?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Heavy Housework?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Light Housework?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Shopping?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
Transportation?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown
During the past 7 days, how would you rate your ability to perform:
Telephone Use?:
0 - Independent
1 - Supervision
2 - Limited Assistance
3 - Mostly Dependent
4 - Totally Dependent
5 - Activity does not occur / or unknown