INTAKE QUESTIONNAIRE This is the first set of questions we ask a potential new customer for RSC Step 1 of 5 20% Name First Last PhoneEmail Do you have an Amazon Account? YES No Loved one's Name Their Zip Code ZIP / Postal Code Do they have an Amazon Account? YES No Do they have a smart phone or a tablet? Yes No Their AgePlease enter a number less than or equal to 3.Their GenderMaleFemale Is there a second person living there? Yes No If so, what is the relation to primary resident? Rate their mobility (1-10) with 1 being very limited mobility and 10 being excellent mobility12345678910Rate their hearing (1-10)12345678910General health summary: Please tell us about their general situation in just a sentence or two.Basic Mental SummaryMorning pills? Please check one Yes No Evening pills? Please check one Yes No Are there regular visiting care practitioners? Please fill in the dates and times of all regularly scheduled visiting care practitioners Typical waking time (range is ok)Typical bedtime (range is ok)Is there an optimal time of day or day(s) of the week to have an RSC team member drop in virtually for 20 minutes?Any Daily Routines such as bath times, breakfast times, nap times, etc. How much TV time per day? Are they chatty or they don’t like to talk so much: Rate 1-5 (where 1 is quiet and 5 is chatty)12345Favorite TV Shows Favorite Music Topics to avoid Preferred colors for hardware, (video unit) black or white? Who is your loved one's internet provider, the internet speed if available? Do you currently have Alexa or Google Home devices in your house? (Yes/No) Yes No If so, please list what rooms are the devices located and if they have video or not? We usually recommend putting our Video Alexa Show 10 in the Kitchen so you can share meals and alternately in the Den where they spend a lot of time. Does that make sense for their home? For safety it is recommended that a non video device is placed in their bedroom and their Primary bathroom. OK? Yes No Do you currently have a security system or camera? Yes No If you have cameras, what do you see and what service do you use, if any? Rate the internet speed and reliability as your loved ones house as far as you know. Slow Moderate Fast
