Healthcare Quiz Are you currently in a hospital or have you been in the hospital anytime in the past 30 days?* Yes No Are you looking for more therapy or nursing services?* Yes No Do you have continued medical problems that you feel require therapy services or ongoing nursing care?* Yes No Do you have a prolonged hospital stay or require DAILY doctor visits for any of the following medical problems?*Mechanical Ventilation Tracheostomy care High flow oxygen needs IV Therapy for long period of time or needed multiple times a day Alternative food intake via a Dubhoff or nasal gastric (NG) feeding tube or Total parenteral nutrition (TPN) New or increased dialysis Long term dialysis with additional needs to become more medically stable Wound management that needs special treatment Heart conditions that require electronic monitoring Frequent labs needed to determine correct dose of medications or for monitoring of serious medical condition Yes No Do you have a terminal condition, or frequent hospitalizations within the past few months?* Yes No Do you have a terminal condition, or frequent hospitalizations within the past few months?* Yes No Do you have a terminal condition, or frequent hospitalizations within the past few months?* Yes No Do you want to be admitted to an inpatient rehab facility with a goal to go home?* Yes No Do you want to be admitted to an inpatient rehab facility with a goal to go home?* Yes No Have you been admitted to the hospital for 3 overnight stays now or in the past 30 days?* Yes No Have you been admitted to the hospital for 3 overnight stays now or in the past 30 days?* Yes No Are you looking for an inpatient therapy program?* Yes No Are you looking for an inpatient therapy program?* Yes No Are you interested in moving to a setting that has additional help?* Yes No Are you interested in moving to a setting that has additional help?* Yes No Are you able to leave your home with NO assistance?* Yes No Are you able to leave your home with NO assistance?* Yes No Can you participate in and benefit from 3 one-hour sessions of therapy a day?* Yes No Can you participate in and benefit from 3 one-hour sessions of therapy a day?* Yes No Can you participate in and benefit from 3 one-hour sessions of therapy a day?* Yes No Can you participate in and benefit from 3 one-hour sessions of therapy a day?* Yes No Do you want to receive a copy of your answers and results by email? (optional)
