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Membership information
Membership:
PLATINUM
Call Frequency: THREE CALLS DAILY
Morning call
8:00 - 12:00
8:00 - 10:00
10:00 - 12:00
Afternoon call
12:00 - 17:00
12:00 - 14:00
14:00 - 16:00
15:00 - 17:00
Evening call
17:00 - 21:00
17:00 - 19:00
19:00 - 21:00
19:00 - 22:00
Caregiver information
Name
Phone (will use as WA-notification and emergency)
Email
Elderly information
Elderly's name
Elderly's phone
Elderly's language
English
Hindi
Malayalam
Telugu
Elderly's Gender
Male
Female
Check the conditions that apply:
Asthma
Cancer
Cardiac disease
Diabetes
Blood Pressure
Thyroid disease
Bronchitis
Heart Disease
Cholesterol
Gastrointestinal disease
Hearing loss
Arthritis
Chronic Kidney ailments
Chronic Obstructive pulmonary disease
Dementia
Alzheimers
Parkinsons
Osteoporosis
Eye health issues
Gynecological problems
Skin problems
Oral health
Stroke
UTI
Incontinence
Depression
Anxiety
Excess smoking
Excess Alcohol
Obesity
Falls/Injuries/Accidents
Liver disease
Your answer
Any symptoms that elderly has experienced in the past 6 weeks
Fever/Chills
Unexplained change in weight
Fatigue/Malaise/Generalized weakness
Headaches/Migraines
Dizziness
Sinus Pain/Pressure/Discharge
Excessive snoring
Wheezing/Chronic Cough
Shortness of breath
Chest pain, pressure or tightness
Swelling of hands/feet/ankles
Nausea/Vomiting
Abdominal pain
Heartburn
Constipation or diarrhea
Stiffness/Pain in joints/muscles
Joint swelling
Bleeding/Easy bruising
Excessive urination
Excessive thirst/hunger
Hot flashes
Painful/Bloody urination
Difficulty urinating/Night-time urination
Urinary incontinence (leakage)
Rash
Anxiety/Panic Attacks
Concentration Difficulty
Feelings of Guilt
Insomnia/Problems with Sleep
Loss of energy
Thoughts of harming self or others
Your answer
Any medications taken
Yes
No
List of medications, supplements, their schedule as elaborated below and any other ongoing treatment
Does the elderly exercise/ go for walks?
Yes
No
Not sure
Does the elderly have a history of using tobacco?
Yes
No
Not Sure
In the past
Does the elderly consume alcohol?
Yes
No
Not Sure
In the past
How healthy does the elderly feel in general?
1
10
Elderly's Hobby
Elderly's living address
Additional information
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