Common form - Aaji Care

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Aaji care updated 01

Phone : +91 9920018184

Service

Dementia Care Solutions

Patient Care at Home

Assisted Living Centres

Mumbai Centres

Pune Centres

Goa Centres

Dementia Care Solutions
Patient Care at Home
Assisted Living Centre

Mumbai
Elder Care Centre in Goa
Elder Care Centre in Pune

Common Form

First Name *

Last Name *

Email

Mobile *

What is the age of Elder/Patient?

Who is this service for?

Initial Service Type

Lead Source

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Dementia Care Solutions

Patient Care at Home

Assisted Living Center

Location

Versova (Mumbai)

D N Nagar (Mumbai)

Thane (Mumbai)

Old Goa (Goa)

Kalyani Nagar (Pune)

Your Care Journey Starts Here!

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Your First Step to Expert Care

Name

Mobile Number

Email ID

Select Service

Select Location

Type Message

Blank Form (#3)

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
Step 11
Step 12
Step 13

1/12

How often do you get a good night's sleep (seven or more hours)?

Every day

Often

Sometimes

Seldom or never

2/12

How often do you keep up with leisure activities that you enjoyed before caregiving?

Every day

Often

Sometimes

Seldom or never

3/12

How often do you feel irritable or lose your temper with others?

Seldom or never

Sometimes

Often

Every day

4/12

How often do you feel happy?

Every day

Sometimes

Often

Seldom or never

5/12

How often do you find it difficult to concentrate?

Often

Seldom or never

Every day

Sometimes

6/12

How often do you need a cigarette(s) or more than two cups of coffee to make it through the day?

Seldom or never

Often

Every day

Sometimes

7/12

How often do you lack the energy to cook, clean, and take care of everyday basics?

Every day

Sometimes

Often

Seldom or never

8/12

How often do you feel hopeless about the future?

Seldom or never

Often

Sometimes

Every day

9/12

How often are you able to relax without the use of alcohol or prescription sedatives?

Every day

Sometimes

Often

Seldom or never

10/12

How often do you feel overwhelmed by all you have to do?

Every day

Sometimes

Often

Seldom or never

11/12

How often has someone criticized your caregiving or suggested you're burning out?

Every day

Sometimes

Often

Seldom or never

12/12

How often do you feel that someone is looking after or caring for you?

Seldom or never

Every day

Often

Sometimes

Tagline - Assessment Result will be sent to you by mail

Your First Step to Expert Care

Your First Step to Expert Care

Your First Step to Expert Care

Your First Step to Expert Care

caregiver

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
Step 11
Step 12
Step 13
Step 14

1/13

Do you often feel overwhelmed, anxious, or helpless?

Yes

No

2/13

Have you experienced mood swings, irritability, or sudden sadness?

Yes

No

3/13

Do you feel emotionally drained or numb at the end of the day?

Yes

No

4/13

Are you sleeping less than 6 hours or experiencing poor sleep quality?

Yes

No

5/13

Do you feel physically exhausted, even after resting?

Yes

No

6/13

Have you developed frequent headaches, body aches, or digestion issues?

Yes

No

7/13

Do you find it hard to concentrate, make decisions, or stay organized?

Yes

No

8/13

Do you feel like you're constantly “on edge” or tense?

Yes

No

9/13

Have you stopped doing things you enjoy (hobbies, social outings, exercise)?

Yes

No

10/13

Do you struggle to make time for your own medical appointments or self-care?

Yes

No

11/13

Do you feel guilty taking breaks or asking others for help?

Yes

No

12/13

Do you feel isolated or that no one truly understands what you’re going through?

Yes

No

13/13

Has caregiving impacted your relationship with friends, family, or partner?

Yes

No

Tagline - Assessment Result will be sent to you by mail

cognitive

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Step 10
Step 11

1/10

Forget names of close friends or family members often

Yes

No

2/10

Frequently misplace items (keys, glasses, wallet) and struggle to find them

Yes

No

3/10

Get confused about the day, date, or time of day?

Yes

No

4/10

Find yourself lost in a familiar place?

Yes

No

5/10

Struggle to find the right words while speaking or forget what you were saying mid-sentence?

Yes

No

6/10

Repeat the same questions or stories during a conversation?

Yes

No

7/10

Have difficulty managing finances, appointments, or medications lately?

Yes

No

8/10

Need more help with daily tasks (cooking, shopping, handling phone calls) than you used to?

Yes

No

9/10

Have become more withdrawn, anxious, irritable, or suspicious than before?

Yes

No

10/10

Have friends or family noticed changes in your behaviour or personality?

Yes

No

Tagline - Assessment Result will be sent to you by mail