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2625 West Touhy Avenue
Chicago, Illinois 60645

Phone: 773-973-5333
Fax: 773-973-5222
Email: info@buckinghampavilion.com

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Step 1 of 25

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I am taking this Care Questionnaire for:*
- Myself
- My Parents
- My Spouse
- A Patient
- Someone Else

Are you experiencing any of the following?
- Trouble Hearing / Hearing loss
- Low Vision / Difficulty Seeing
- Difficulty Walking
- Difficulty Eating
- Depression
- Falling
Check all that apply or if none click next.

Have you stayed in any of the following in the last 6 months?
- Hospital
- Rehab/Skilled Nursing Facility
- Assisted Living Facility
- In-Patient Stay
Check all that apply or if none click next.

Do you need someone to help you with any of the following?
- Getting Dressed
- Bathing
- Using the bathroom
- Preparing Meals
- Taking Medications
Check all that apply or if none click next.

Do you have difficulty remembering things such as paying your bills each month?*
- Yes
- No

Have you ever been diagnosed with dementia or Alzheimer's?*
- Yes
- No

Have you ever wandered or driven away from a known location and felt disoriented or lost?*
- Yes
- No

Do you have additional information to share? (Optional):
Name*
Email*
Phone*
Results
- Get Results
Results
- Get Results
Results
- Get Results

Does your loved one require in-home support 24 hours a day?*
- Yes
- No

Is your loved one experiencing any of the following?
- Trouble Hearing / Hearing loss
- Low Vision / Difficulty Seeing
- Difficulty Walking
- Difficulty Eating
- Depression
- Falling
Check all that apply or if none click next.

Has your loved one stayed in any of the following in the last 6 months?
- Hospital
- Rehab/Skilled Nursing Facility
- Assisted Living Facility
- In-Patient Stay
Check all that apply or if none click next.

Does your loved one need someone to help them with any of the following?
- Getting Dressed
- Bathing
- Using the bathroom
- Preparing Meals
- Taking Medications
Check all that apply or if none click next.

Is your loved one having difficulty remembering things such as paying their bills each month?*
- Yes
- No

Is your loved one ever been diagnosed with dementia or Alzheimer's?*
- Yes
- No

Has your loved one ever wandered or driven away from a known location and felt disoriented or lost?*
- Yes
- No

Do you have additional information to share? (Optional):
Name*
Email*
Phone*
Results
- Get Results
Results
- Get Results
Results
- Get Results

Do they require in-home support 24 hours a day?*
- Yes
- No

Are they experiencing any of the following?
- Trouble Hearing / Hearing loss
- Low Vision / Difficulty Seeing
- Difficulty Walking
- Difficulty Eating
- Depression
- Falling
Check all that apply or if none click next.

Have they stayed in any of the following in the last 6 months?
- Hospital
- Rehab/Skilled Nursing Facility
- Assisted Living Facility
- In-Patient Stay
Check all that apply or if none click next.

Do they need someone to help them with any of the following?
- Getting Dressed
- Bathing
- Using the bathroom
- Preparing Meals
- Taking Medications
Check all that apply or if none click next.

Do they have difficulty remembering things such as paying their bills each month?*
- Yes
- No

Have they ever been diagnosed with dementia or Alzheimer's?*
- Yes
- No

Have they ever wandered or driven away from a known location and felt disoriented or lost?*
- Yes
- No

Do you have additional information to share? (Optional):
Name*
Email*
Phone*
Results
- Get Results
Results
- Get Results
Results
- Get Results

Result

You may need memory care

WhatsApp Image 2022-04-26 at 2.30.38 PM

WhatsApp Image 2022-04-26 at 2.30.39 PM (1)

WhatsApp Image 2022-04-26 at 2.30.39 PM

WhatsApp Image 2022-04-26 at 2.30.38 PM (2)

WhatsApp Image 2022-04-26 at 2.30.38 PM (1)

*This is not an assessment by a licensed professional and should not be taken as a diagnosis by a physician. You will need to speak to a All Seasons Senior Living representative to validate the results of this questionnaire.
When you speak to a All Seasons Senior Living representative it will be determined if we can meet your care needs. If it is determined we can, then the level of care will be selected. The results of the assessment are owned by All Seasons Senior Living and should not be considered a health care diagnosis/evaluation.

Schedule a Tour

Name*
Email*
Phone*
What services are you interested in?*
- Assisted Living Plus
- Memory Care
- Skilled Nursing
- Rehabilitation & Transitional Care
- Parkinson's Care
- Long Term Care
You are interested in Buckingham Pavilion for:*
- Yourself
- A Family Member
- A Friend
- A Client
- Other

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