Questionnaire: Google Form (Test) - Carenote

Carenote Loneliness Evaluation

Fill out our 30 second evaluation questionnaire to see if you qualify for Carenote's loneliness service.

* Required

Under 55 55 to 64 65 to 74 75 and over Good Ok Bad 1 2 3 4 5 6 7 8 9 10 Morning Afternoon Evening Never Occasionally Always Never Occasionally Frequently (more than twice) Never Occasionally Frequently (more than twice) Extroverted Introverted Other Never Occasionally Always Good Average Bad Never Occasionally Always I live with a spouse or partner I live with family I live alone I live in a retirement or assisted living facility Other: Divorce or spouse passed away Kids moved away from home Friends relocated or passed away Other: Companionship / I feel lonely and need someone to talk to Support / I need someone to help manage my daily activities Other: Daily Activities / Hobbies Loved Ones / Family Health / Aging Faith / Religion Pets Other: