BeHomeSafe

First name

Last name

Email address

Address

City

Zip Code

Additional Contact Information

First name

Last name

Email address

Address

City

Zip Code

Relationship

Fall Hazards

Attached Garage?

Yes

Other (Please specify)

First Floor Laundry?

Yes

Other (Please specify)

First Floor Master Bedroom?

Yes

Other (Please specify)

Assisted Equipment

Does your home have safety equipment installed?

Bedrails

Hospital Bed

Bed Commode

Grab Bars

Lift Chair

Raised Toilet Seat

Shower Bench

Handheld Shower Head

Other (Please specify)

Health

How many times admitted to the hospital in the last year?

More than 5

Other (Please specify)

Medication Management

How many medications do you take each day?

What time of day do you take medications?

Morning

Mid-Day

Evening

Would it help to have medication reminders?

Yes

Professional Recommendation

Do you have a Power of Attorney and Living Will in place?

Yes

Professional Recommendation

Would you like to have access to your medical records across all Electronic Health Record systems?

Yes

Professional Recommendation

Meal Management

Do you have a meal prep / delivery service?

Yes

Professional Recommendation

Please select what days per week that you eat at home

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Please select how often you clean out your refrigerator?

Once per week

Once per month

Professional Recommendation

Please indicate how healthy your food choices are?

Please indicate how often you cook your own meals?

Once per week

2-5 times per week

6 - 10 times per week

More than 10 times per week

Please indicate how often you use your stove/oven to cook meals?

Once per week

2-5 times per week

6 - 10 times per week

More than 10 times per week

Notes

How active are you?

Notes

Do you drive?

Yes

Do you need rides to any of the following

Doctor Appointments

Grocery Store

Restaurants

Senior Center

Notes

How often do you speak with your Circle of Care?

Less than once per week

2-3 times per week

Regularly speak with members of circle of care each week

Notes

How often do you speak with your Grandchildren?

Less than once per month

2-3 times per month

Regularly speak with them each month

Notes

Would you like to communicate with your children / grandchildren / out of town friends more often?

Yes

How comfortable are you with technology?

Would you like to be connected with loved ones and professional care givers through technology as long as it was easy and passive?

Yes

Do you have pets?

Yes

Submit

Thanks!

We're putting together your personalized results.

Security

ONKÖL + Door sensor and Motion sensor
ONKÖL + Temp/Humidity

Home Automation

ONKÖL + Yale Real Living deadbolt
ONKÖL + Zigbee lightbulbs

Health & Wellness

ONKÖL + related peripherals
ONKÖL + related peripherals

OneChart

Mobile PERS

iHelp
Sky

Home Modifications

101 Mobility
ONKÖL + related peripherals

Meal Delivery

ONKÖL + door sensors for refrigerator, microwave, stove
Introduction to local delivery services

Transportation Services

Mobile PERS
Referral to Transportation services

Senior Tablet

BHS Tablet

Prescription

ONKÖL + medication reminders
Referral to pharmacy with delivery options

Additional Contact Information

Fall Hazards

Select Rooms with Fall Hazards

Attached Garage?

First Floor Laundry?

First Floor Master Bedroom?

Assisted Equipment

Does your home have safety equipment installed?

Health

Please select all chronic conditions that apply

How many times admitted to the hospital in the last year?

Medication Management

How many medications do you take each day?

What time of day do you take medications?

Would it help to have medication reminders?

Do you have a Power of Attorney and Living Will in place?

Would you like to have access to your medical records across all Electronic Health Record systems?

Meal Management

Do you have a meal prep / delivery service?

Please select what days per week that you eat at home

Please select how often you clean out your refrigerator?

Please indicate how healthy your food choices are?

Please indicate how often you cook your own meals?

Please indicate how often you use your stove/oven to cook meals?

How active are you?

Do you drive?

Do you need rides to any of the following

How often do you speak with your Circle of Care?

How often do you speak with your Grandchildren?

Would you like to communicate with your children / grandchildren / out of town friends more often?

How comfortable are you with technology?

Would you like to be connected with loved ones and professional care givers through technology as long as it was easy and passive?

Do you have pets?

Recommendations

We're putting together your personalized results.

Security

Home Automation

Health & Wellness

OneChart

Mobile PERS

Home Modifications

Meal Delivery

Transportation Services

Senior Tablet

Prescription

Attorney Recommendations

Please provide a copy of the Power of Attorney and Living Will.