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Please answer the following questions. Your response will help the Older Adults Ministry understand your living situation and determine the best services to support your needs.

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* 1. Do you attend the Capitol Hill SDA Church?

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* 2. What is your age range?

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* 3. What is the age range of the person you care for?

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* 4. In my home, I live:

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* 5. Is your house or apartment

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* 6. What is your sex

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* 7. Do you need assistance in caring for yourself?

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* 8. Do you need help in caring for a loved one?

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* 9. Were you diagnosed with dementia?

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* 10. Do you care for someone who has dementia?

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* 11. Do you know someone living with dementia?

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* 12. Do you or a loved one need help with the following: walking, dressing, grooming, eating/feeding, toileting, or getting in and out of bed or a chair?

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* 13.  I need assistance with (check all that apply)

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