Caregiver details for Caregiver Roadmap These questions are CONFIDENTIAL and will help your Caregiver Liaison know more about your Caregiving journey. We thank you for taking the time to fill this out.Where you see an asterisk, it is not required information, but could help us with understanding your situation a little better.Caregiver Name:* First Last Caregiver Email:* Phone Number of Caregiver:Address of Caregiver: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of Loved One you are Caring for: First Last Relationship to your Loved One: *Age of Loved One:Where does your Loved One reside? *What services are you currently using? (check all that apply) Home Care (sitter, transportation, light housekeeping, and meal prep) Home Health (Physical Therapy, Occupational Therapy, Speech Therapy) Adult Day Care Independent Living Community Assisted Living Facility Skilled Nursing Facility *What are your struggles as a Caregiver*What is it that you hope to get out of a Roadmap?Who is in your “Support System?” (Friends, Family, Place of Worship, etc.…)Who are the people you wish you had support from? (Out of town family, kids, spouse, etc.…)*Do you feel stressed about being a Caregiver? What kind of health is your Loved One in? What diagnosis does your Loved One have? If any diagnosis, where did you receive diagnosis from? Are there behaviors that you find difficult or embarrassing to manage with your Loved One?*What meds is your Loved One on?What physical problems does your Loved One have? Check all that apply. Fall risk Cane Walker Wheelchair Bed bound *As a Caregiver are you a part of a Support Group? Yes No Which ones?*Do you need resources currently? Check all that apply. Home Care Home Health Adult Day Centers Assisted Living Independent Living Skilled Nursing Realtor Support Group Elder Law Attorney Financial Planner Medicare Consultant Physician Accountant Reverse Mortgage Specialist Care Manager Senior Placement Specialist We’re here to help Caregivers as best we can.