CNA/HHA Assessment Form

img:is([sizes=auto i],[sizes^="auto," i]){contain-intrinsic-size:3000px 1500px}img.wp-smiley,img.emoji{display:inline !important;border:none !important;box-shadow:none !important;height:1em !important;width:1em !important;margin:0 .07em !important;vertical-align:-.1em !important;background:none !important;padding:0 !important}:root{--wp--preset--aspect-ratio--square:1;--wp--preset--aspect-ratio--4-3:4/3;--wp--preset--aspect-ratio--3-4:3/4;--wp--preset--aspect-ratio--3-2:3/2;--wp--preset--aspect-ratio--2-3:2/3;--wp--preset--aspect-ratio--16-9:16/9;--wp--preset--aspect-ratio--9-16:9/16;--wp--preset--color--black:#000;--wp--preset--color--cyan-bluish-gray:#abb8c3;--wp--preset--color--white:#fff;--wp--preset--color--pale-pink:#f78da7;--wp--preset--color--vivid-red:#cf2e2e;--wp--preset--color--luminous-vivid-orange:#ff6900;--wp--preset--color--luminous-vivid-amber:#fcb900;--wp--preset--color--light-green-cyan:#7bdcb5;--wp--preset--color--vivid-green-cyan:#00d084;--wp--preset--color--pale-cyan-blue:#8ed1fc;--wp--preset--color--vivid-cyan-blue:#0693e3;--wp--preset--color--vivid-purple:#9b51e0;--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple:linear-gradient(135deg,#0693e3 0%,#9b51e0 100%);--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan:linear-gradient(135deg,#7adcb4 0%,#00d082 100%);--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange:linear-gradient(135deg,#fcb900 0%,#ff6900 100%);--wp--preset--gradient--luminous-vivid-orange-to-vivid-red:linear-gradient(135deg,#ff6900 0%,#cf2e2e 100%);--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray:linear-gradient(135deg,#eee 0%,#a9b8c3 100%);--wp--preset--gradient--cool-to-warm-spectrum:linear-gradient(135deg,#4aeadc 0%,#9778d1 20%,#cf2aba 40%,#ee2c82 60%,#fb6962 80%,#fef84c 100%);--wp--preset--gradient--blush-light-purple:linear-gradient(135deg,#ffceec 0%,#9896f0 100%);--wp--preset--gradient--blush-bordeaux:linear-gradient(135deg,#fecda5 0%,#fe2d2d 50%,#6b003e 100%);--wp--preset--gradient--luminous-dusk:linear-gradient(135deg,#ffcb70 0%,#c751c0 50%,#4158d0 100%);--wp--preset--gradient--pale-ocean:linear-gradient(135deg,#fff5cb 0%,#b6e3d4 50%,#33a7b5 100%);--wp--preset--gradient--electric-grass:linear-gradient(135deg,#caf880 0%,#71ce7e 100%);--wp--preset--gradient--midnight:linear-gradient(135deg,#020381 0%,#2874fc 100%);--wp--preset--font-size--small:13px;--wp--preset--font-size--medium:20px;--wp--preset--font-size--large:36px;--wp--preset--font-size--x-large:42px;--wp--preset--spacing--20:.44rem;--wp--preset--spacing--30:.67rem;--wp--preset--spacing--40:1rem;--wp--preset--spacing--50:1.5rem;--wp--preset--spacing--60:2.25rem;--wp--preset--spacing--70:3.38rem;--wp--preset--spacing--80:5.06rem;--wp--preset--shadow--natural:6px 6px 9px rgba(0,0,0,.2);--wp--preset--shadow--deep:12px 12px 50px rgba(0,0,0,.4);--wp--preset--shadow--sharp:6px 6px 0px rgba(0,0,0,.2);--wp--preset--shadow--outlined:6px 6px 0px -3px #fff,6px 6px #000;--wp--preset--shadow--crisp:6px 6px 0px #000}:root{--wp--style--global--content-size:800px;--wp--style--global--wide-size:1200px}:where(body){margin:0}.wp-site-blocks > .alignleft{float:left;margin-right:2em}.wp-site-blocks > .alignright{float:right;margin-left:2em}.wp-site-blocks > .aligncenter{justify-content:center;margin-left:auto;margin-right:auto}:where(.wp-site-blocks) > *{margin-block-start:24px;margin-block-end:0}:where(.wp-site-blocks) > :first-child{margin-block-start:0}:where(.wp-site-blocks) > :last-child{margin-block-end:0}:root{--wp--style--block-gap:24px}:root :where(.is-layout-flow) > :first-child{margin-block-start:0}:root :where(.is-layout-flow) > :last-child{margin-block-end:0}:root :where(.is-layout-flow) > *{margin-block-start:24px;margin-block-end:0}:root :where(.is-layout-constrained) > :first-child{margin-block-start:0}:root :where(.is-layout-constrained) > :last-child{margin-block-end:0}:root :where(.is-layout-constrained) > *{margin-block-start:24px;margin-block-end:0}:root :where(.is-layout-flex){gap:24px}:root :where(.is-layout-grid){gap:24px}.is-layout-flow > .alignleft{float:left;margin-inline-start:0;margin-inline-end:2em}.is-layout-flow > .alignright{float:right;margin-inline-start:2em;margin-inline-end:0}.is-layout-flow > .aligncenter{margin-left:auto !important;margin-right:auto !important}.is-layout-constrained > .alignleft{float:left;margin-inline-start:0;margin-inline-end:2em}.is-layout-constrained > .alignright{float:right;margin-inline-start:2em;margin-inline-end:0}.is-layout-constrained > .aligncenter{margin-left:auto !important;margin-right:auto !important}.is-layout-constrained > :where(:not(.alignleft):not(.alignright):not(.alignfull)){max-width:var(--wp--style--global--content-size);margin-left:auto !important;margin-right:auto !important}.is-layout-constrained > .alignwide{max-width:var(--wp--style--global--wide-size)}body .is-layout-flex{display:flex}.is-layout-flex{flex-wrap:wrap;align-items:center}.is-layout-flex > :is(*, div){margin:0}body .is-layout-grid{display:grid}.is-layout-grid > :is(*, div){margin:0}body{padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px}a:where(:not(.wp-element-button)){text-decoration:underline}:root :where(.wp-element-button, .wp-block-button__link){background-color:#32373c;border-width:0;color:#fff;font-family:inherit;font-size:inherit;font-style:inherit;font-weight:inherit;letter-spacing:inherit;line-height:inherit;padding-top:calc(.667em + 2px);padding-right:calc(1.333em + 2px);padding-bottom:calc(.667em + 2px);padding-left:calc(1.333em + 2px);text-decoration:none;text-transform:inherit}.has-black-color{color:var(--wp--preset--color--black) !important}.has-cyan-bluish-gray-color{color:var(--wp--preset--color--cyan-bluish-gray) !important}.has-white-color{color:var(--wp--preset--color--white) !important}.has-pale-pink-color{color:var(--wp--preset--color--pale-pink) !important}.has-vivid-red-color{color:var(--wp--preset--color--vivid-red) !important}.has-luminous-vivid-orange-color{color:var(--wp--preset--color--luminous-vivid-orange) !important}.has-luminous-vivid-amber-color{color:var(--wp--preset--color--luminous-vivid-amber) !important}.has-light-green-cyan-color{color:var(--wp--preset--color--light-green-cyan) !important}.has-vivid-green-cyan-color{color:var(--wp--preset--color--vivid-green-cyan) !important}.has-pale-cyan-blue-color{color:var(--wp--preset--color--pale-cyan-blue) !important}.has-vivid-cyan-blue-color{color:var(--wp--preset--color--vivid-cyan-blue) !important}.has-vivid-purple-color{color:var(--wp--preset--color--vivid-purple) !important}.has-black-background-color{background-color:var(--wp--preset--color--black) !important}.has-cyan-bluish-gray-background-color{background-color:var(--wp--preset--color--cyan-bluish-gray) !important}.has-white-background-color{background-color:var(--wp--preset--color--white) !important}.has-pale-pink-background-color{background-color:var(--wp--preset--color--pale-pink) !important}.has-vivid-red-background-color{background-color:var(--wp--preset--color--vivid-red) !important}.has-luminous-vivid-orange-background-color{background-color:var(--wp--preset--color--luminous-vivid-orange) !important}.has-luminous-vivid-amber-background-color{background-color:var(--wp--preset--color--luminous-vivid-amber) !important}.has-light-green-cyan-background-color{background-color:var(--wp--preset--color--light-green-cyan) !important}.has-vivid-green-cyan-background-color{background-color:var(--wp--preset--color--vivid-green-cyan) !important}.has-pale-cyan-blue-background-color{background-color:var(--wp--preset--color--pale-cyan-blue) !important}.has-vivid-cyan-blue-background-color{background-color:var(--wp--preset--color--vivid-cyan-blue) !important}.has-vivid-purple-background-color{background-color:var(--wp--preset--color--vivid-purple) !important}.has-black-border-color{border-color:var(--wp--preset--color--black) !important}.has-cyan-bluish-gray-border-color{border-color:var(--wp--preset--color--cyan-bluish-gray) !important}.has-white-border-color{border-color:var(--wp--preset--color--white) !important}.has-pale-pink-border-color{border-color:var(--wp--preset--color--pale-pink) !important}.has-vivid-red-border-color{border-color:var(--wp--preset--color--vivid-red) !important}.has-luminous-vivid-orange-border-color{border-color:var(--wp--preset--color--luminous-vivid-orange) !important}.has-luminous-vivid-amber-border-color{border-color:var(--wp--preset--color--luminous-vivid-amber) !important}.has-light-green-cyan-border-color{border-color:var(--wp--preset--color--light-green-cyan) !important}.has-vivid-green-cyan-border-color{border-color:var(--wp--preset--color--vivid-green-cyan) !important}.has-pale-cyan-blue-border-color{border-color:var(--wp--preset--color--pale-cyan-blue) !important}.has-vivid-cyan-blue-border-color{border-color:var(--wp--preset--color--vivid-cyan-blue) !important}.has-vivid-purple-border-color{border-color:var(--wp--preset--color--vivid-purple) !important}.has-vivid-cyan-blue-to-vivid-purple-gradient-background{background:var(--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple) !important}.has-light-green-cyan-to-vivid-green-cyan-gradient-background{background:var(--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan) !important}.has-luminous-vivid-amber-to-luminous-vivid-orange-gradient-background{background:var(--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange) !important}.has-luminous-vivid-orange-to-vivid-red-gradient-background{background:var(--wp--preset--gradient--luminous-vivid-orange-to-vivid-red) !important}.has-very-light-gray-to-cyan-bluish-gray-gradient-background{background:var(--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray) !important}.has-cool-to-warm-spectrum-gradient-background{background:var(--wp--preset--gradient--cool-to-warm-spectrum) !important}.has-blush-light-purple-gradient-background{background:var(--wp--preset--gradient--blush-light-purple) !important}.has-blush-bordeaux-gradient-background{background:var(--wp--preset--gradient--blush-bordeaux) !important}.has-luminous-dusk-gradient-background{background:var(--wp--preset--gradient--luminous-dusk) !important}.has-pale-ocean-gradient-background{background:var(--wp--preset--gradient--pale-ocean) !important}.has-electric-grass-gradient-background{background:var(--wp--preset--gradient--electric-grass) !important}.has-midnight-gradient-background{background:var(--wp--preset--gradient--midnight) !important}.has-small-font-size{font-size:var(--wp--preset--font-size--small) !important}.has-medium-font-size{font-size:var(--wp--preset--font-size--medium) !important}.has-large-font-size{font-size:var(--wp--preset--font-size--large) !important}.has-x-large-font-size{font-size:var(--wp--preset--font-size--x-large) !important}:root :where(.wp-block-pullquote){font-size:1.5em;line-height:1.6}:root{--eb-global-primary-color:#101828;--eb-global-secondary-color:#475467;--eb-global-tertiary-color:#98a2b3;--eb-global-text-color:#475467;--eb-global-heading-color:#1d2939;--eb-global-link-color:#444ce7;--eb-global-background-color:#f9fafb;--eb-global-button-text-color:#fff;--eb-global-button-background-color:#101828;--eb-gradient-primary-color:linear-gradient(90deg,hsla(259,84%,78%,1) 0%,hsla(206,67%,75%,1) 100%);--eb-gradient-secondary-color:linear-gradient(90deg,hsla(18,76%,85%,1) 0%,hsla(203,69%,84%,1) 100%);--eb-gradient-tertiary-color:linear-gradient(90deg,hsla(248,21%,15%,1) 0%,hsla(250,14%,61%,1) 100%);--eb-gradient-background-color:linear-gradient(90deg,#fafafa 0%,#e9e9e9 49%,#f4f3f3 100%);--eb-tablet-breakpoint:1024px;--eb-mobile-breakpoint:767px}.e-con.e-parent:nth-of-type(n+4):not(.e-lazyloaded):not(.e-no-lazyload),.e-con.e-parent:nth-of-type(n+4):not(.e-lazyloaded):not(.e-no-lazyload) *{background-image:none !important}@media screen and (max-height: 1024px){.e-con.e-parent:nth-of-type(n+3):not(.e-lazyloaded):not(.e-no-lazyload),.e-con.e-parent:nth-of-type(n+3):not(.e-lazyloaded):not(.e-no-lazyload) *{background-image:none !important}.e-con.e-parent:nth-of-type(n+3):not(.e-lazyloaded):not(.e-no-lazyload).nitro-lazy,.e-con.e-parent:nth-of-type(n+3):not(.e-lazyloaded):not(.e-no-lazyload) *.nitro-lazy{background-image:none !important}}@media screen and (max-height: 640px){.e-con.e-parent:nth-of-type(n+2):not(.e-lazyloaded):not(.e-no-lazyload),.e-con.e-parent:nth-of-type(n+2):not(.e-lazyloaded):not(.e-no-lazyload) *{background-image:none !important}.e-con.e-parent:nth-of-type(n+2):not(.e-lazyloaded):not(.e-no-lazyload).nitro-lazy,.e-con.e-parent:nth-of-type(n+2):not(.e-lazyloaded):not(.e-no-lazyload) *.nitro-lazy{background-image:none !important}}.e-con.e-parent:nth-of-type(n+4):not(.e-lazyloaded):not(.e-no-lazyload).nitro-lazy,.e-con.e-parent:nth-of-type(n+4):not(.e-lazyloaded):not(.e-no-lazyload) *.nitro-lazy{background-image:none !important}@media (max-width:766px){.pafe-sticky-header-fixed-start-on-mobile{position:fixed !important;top:0;width:100%;z-index:99}}@media (min-width:767px) and (max-width:1023px){.pafe-sticky-header-fixed-start-on-tablet{position:fixed !important;top:0;width:100%;z-index:99}}@media (min-width:1024px){.pafe-sticky-header-fixed-start-on-desktop{position:fixed !important;top:0;width:100%;z-index:99}}.pswp.pafe-lightbox-modal{display:none}.woocommerce-checkout .c4wp_captcha_field{margin-bottom:10px;margin-top:15px;position:relative;display:inline-block}.login #login,.login #lostpasswordform{min-width:350px !important}.wpforms-field-c4wp iframe{width:100% !important}.login #login,.login #lostpasswordform{min-width:350px !important}.wpforms-field-c4wp iframe{width:100% !important}#gform_wrapper_5[data-form-index="0"].gform-theme,[data-parent-form="5_0"]{--gf-color-primary:#204ce5;--gf-color-primary-rgb:32,76,229;--gf-color-primary-contrast:#fff;--gf-color-primary-contrast-rgb:255,255,255;--gf-color-primary-darker:#001ab3;--gf-color-primary-lighter:#527eff;--gf-color-secondary:#fff;--gf-color-secondary-rgb:255,255,255;--gf-color-secondary-contrast:#112337;--gf-color-secondary-contrast-rgb:17,35,55;--gf-color-secondary-darker:#f5f5f5;--gf-color-secondary-lighter:#fff;--gf-color-out-ctrl-light:rgba(17,35,55,.1);--gf-color-out-ctrl-light-rgb:17,35,55;--gf-color-out-ctrl-light-darker:rgba(104,110,119,.35);--gf-color-out-ctrl-light-lighter:#f5f5f5;--gf-color-out-ctrl-dark:#585e6a;--gf-color-out-ctrl-dark-rgb:88,94,106;--gf-color-out-ctrl-dark-darker:#112337;--gf-color-out-ctrl-dark-lighter:rgba(17,35,55,.65);--gf-color-in-ctrl:#fff;--gf-color-in-ctrl-rgb:255,255,255;--gf-color-in-ctrl-contrast:#112337;--gf-color-in-ctrl-contrast-rgb:17,35,55;--gf-color-in-ctrl-darker:#f5f5f5;--gf-color-in-ctrl-lighter:#fff;--gf-color-in-ctrl-primary:#204ce5;--gf-color-in-ctrl-primary-rgb:32,76,229;--gf-color-in-ctrl-primary-contrast:#fff;--gf-color-in-ctrl-primary-contrast-rgb:255,255,255;--gf-color-in-ctrl-primary-darker:#001ab3;--gf-color-in-ctrl-primary-lighter:#527eff;--gf-color-in-ctrl-light:rgba(17,35,55,.1);--gf-color-in-ctrl-light-rgb:17,35,55;--gf-color-in-ctrl-light-darker:rgba(104,110,119,.35);--gf-color-in-ctrl-light-lighter:#f5f5f5;--gf-color-in-ctrl-dark:#585e6a;--gf-color-in-ctrl-dark-rgb:88,94,106;--gf-color-in-ctrl-dark-darker:#112337;--gf-color-in-ctrl-dark-lighter:rgba(17,35,55,.65);--gf-radius:3px;--gf-font-size-secondary:14px;--gf-font-size-tertiary:13px;--gf-icon-ctrl-number:url("data:image/svg+xml,%3Csvg width=\'8\' height=\'14\' viewBox=\'0 0 8 14\' fill=\'none\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath fill-rule=\'evenodd\' clip-rule=\'evenodd\' d=\'M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-icon-ctrl-select:url("data:image/svg+xml,%3Csvg width=\'10\' height=\'6\' viewBox=\'0 0 10 6\' fill=\'none\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath fill-rule=\'evenodd\' clip-rule=\'evenodd\' d=\'M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-icon-ctrl-search:url("data:image/svg+xml,%3Csvg width=\'640\' height=\'640\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath d=\'M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-label-space-y-secondary:var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color:#686e77;--gf-ctrl-size:var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary:#112337;--gf-ctrl-label-color-secondary:#112337;--gf-ctrl-choice-size:var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size:var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size:var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size:var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x:var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size:var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary:#686e77;--gf-ctrl-file-btn-bg-color-hover:#ebebeb;--gf-field-img-choice-size:var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space:var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size:var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size:var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color:rgba(17,35,55,.8)}#gform_wrapper_3[data-form-index="0"].gform-theme,[data-parent-form="3_0"]{--gf-color-primary:#204ce5;--gf-color-primary-rgb:32,76,229;--gf-color-primary-contrast:#fff;--gf-color-primary-contrast-rgb:255,255,255;--gf-color-primary-darker:#001ab3;--gf-color-primary-lighter:#527eff;--gf-color-secondary:#fff;--gf-color-secondary-rgb:255,255,255;--gf-color-secondary-contrast:#112337;--gf-color-secondary-contrast-rgb:17,35,55;--gf-color-secondary-darker:#f5f5f5;--gf-color-secondary-lighter:#fff;--gf-color-out-ctrl-light:rgba(17,35,55,.1);--gf-color-out-ctrl-light-rgb:17,35,55;--gf-color-out-ctrl-light-darker:rgba(104,110,119,.35);--gf-color-out-ctrl-light-lighter:#f5f5f5;--gf-color-out-ctrl-dark:#585e6a;--gf-color-out-ctrl-dark-rgb:88,94,106;--gf-color-out-ctrl-dark-darker:#112337;--gf-color-out-ctrl-dark-lighter:rgba(17,35,55,.65);--gf-color-in-ctrl:#fff;--gf-color-in-ctrl-rgb:255,255,255;--gf-color-in-ctrl-contrast:#112337;--gf-color-in-ctrl-contrast-rgb:17,35,55;--gf-color-in-ctrl-darker:#f5f5f5;--gf-color-in-ctrl-lighter:#fff;--gf-color-in-ctrl-primary:#204ce5;--gf-color-in-ctrl-primary-rgb:32,76,229;--gf-color-in-ctrl-primary-contrast:#fff;--gf-color-in-ctrl-primary-contrast-rgb:255,255,255;--gf-color-in-ctrl-primary-darker:#001ab3;--gf-color-in-ctrl-primary-lighter:#527eff;--gf-color-in-ctrl-light:rgba(17,35,55,.1);--gf-color-in-ctrl-light-rgb:17,35,55;--gf-color-in-ctrl-light-darker:rgba(104,110,119,.35);--gf-color-in-ctrl-light-lighter:#f5f5f5;--gf-color-in-ctrl-dark:#585e6a;--gf-color-in-ctrl-dark-rgb:88,94,106;--gf-color-in-ctrl-dark-darker:#112337;--gf-color-in-ctrl-dark-lighter:rgba(17,35,55,.65);--gf-radius:3px;--gf-font-size-secondary:14px;--gf-font-size-tertiary:13px;--gf-icon-ctrl-number:url("data:image/svg+xml,%3Csvg width=\'8\' height=\'14\' viewBox=\'0 0 8 14\' fill=\'none\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath fill-rule=\'evenodd\' clip-rule=\'evenodd\' d=\'M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-icon-ctrl-select:url("data:image/svg+xml,%3Csvg width=\'10\' height=\'6\' viewBox=\'0 0 10 6\' fill=\'none\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath fill-rule=\'evenodd\' clip-rule=\'evenodd\' d=\'M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-icon-ctrl-search:url("data:image/svg+xml,%3Csvg width=\'640\' height=\'640\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath d=\'M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-label-space-y-secondary:var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color:#686e77;--gf-ctrl-size:var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary:#112337;--gf-ctrl-label-color-secondary:#112337;--gf-ctrl-choice-size:var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size:var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size:var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size:var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x:var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size:var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary:#686e77;--gf-ctrl-file-btn-bg-color-hover:#ebebeb;--gf-field-img-choice-size:var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space:var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size:var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size:var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color:rgba(17,35,55,.8)}#gform_wrapper_2[data-form-index="0"].gform-theme,[data-parent-form="2_0"]{--gf-color-primary:#204ce5;--gf-color-primary-rgb:32,76,229;--gf-color-primary-contrast:#fff;--gf-color-primary-contrast-rgb:255,255,255;--gf-color-primary-darker:#001ab3;--gf-color-primary-lighter:#527eff;--gf-color-secondary:#fff;--gf-color-secondary-rgb:255,255,255;--gf-color-secondary-contrast:#112337;--gf-color-secondary-contrast-rgb:17,35,55;--gf-color-secondary-darker:#f5f5f5;--gf-color-secondary-lighter:#fff;--gf-color-out-ctrl-light:rgba(17,35,55,.1);--gf-color-out-ctrl-light-rgb:17,35,55;--gf-color-out-ctrl-light-darker:rgba(104,110,119,.35);--gf-color-out-ctrl-light-lighter:#f5f5f5;--gf-color-out-ctrl-dark:#585e6a;--gf-color-out-ctrl-dark-rgb:88,94,106;--gf-color-out-ctrl-dark-darker:#112337;--gf-color-out-ctrl-dark-lighter:rgba(17,35,55,.65);--gf-color-in-ctrl:#fff;--gf-color-in-ctrl-rgb:255,255,255;--gf-color-in-ctrl-contrast:#112337;--gf-color-in-ctrl-contrast-rgb:17,35,55;--gf-color-in-ctrl-darker:#f5f5f5;--gf-color-in-ctrl-lighter:#fff;--gf-color-in-ctrl-primary:#204ce5;--gf-color-in-ctrl-primary-rgb:32,76,229;--gf-color-in-ctrl-primary-contrast:#fff;--gf-color-in-ctrl-primary-contrast-rgb:255,255,255;--gf-color-in-ctrl-primary-darker:#001ab3;--gf-color-in-ctrl-primary-lighter:#527eff;--gf-color-in-ctrl-light:rgba(17,35,55,.1);--gf-color-in-ctrl-light-rgb:17,35,55;--gf-color-in-ctrl-light-darker:rgba(104,110,119,.35);--gf-color-in-ctrl-light-lighter:#f5f5f5;--gf-color-in-ctrl-dark:#585e6a;--gf-color-in-ctrl-dark-rgb:88,94,106;--gf-color-in-ctrl-dark-darker:#112337;--gf-color-in-ctrl-dark-lighter:rgba(17,35,55,.65);--gf-radius:3px;--gf-font-size-secondary:14px;--gf-font-size-tertiary:13px;--gf-icon-ctrl-number:url("data:image/svg+xml,%3Csvg width=\'8\' height=\'14\' viewBox=\'0 0 8 14\' fill=\'none\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath fill-rule=\'evenodd\' clip-rule=\'evenodd\' d=\'M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-icon-ctrl-select:url("data:image/svg+xml,%3Csvg width=\'10\' height=\'6\' viewBox=\'0 0 10 6\' fill=\'none\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath fill-rule=\'evenodd\' clip-rule=\'evenodd\' d=\'M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-icon-ctrl-search:url("data:image/svg+xml,%3Csvg width=\'640\' height=\'640\' xmlns=\'http://www.w3.org/2000/svg\'%3E%3Cpath d=\'M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z\' fill=\'rgba(17, 35, 55, 0.65)\'/%3E%3C/svg%3E");--gf-label-space-y-secondary:var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color:#686e77;--gf-ctrl-size:var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary:#112337;--gf-ctrl-label-color-secondary:#112337;--gf-ctrl-choice-size:var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size:var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size:var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size:var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x:var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size:var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary:#686e77;--gf-ctrl-file-btn-bg-color-hover:#ebebeb;--gf-field-img-choice-size:var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space:var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size:var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size:var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color:rgba(17,35,55,.8)}@media (max-width:766px){.pafe-sticky-header-fixed-start-on-mobile{position:fixed !important;top:0;width:100%;z-index:99}.pafe-display-inline-block-mobile{display:inline-block;margin-bottom:0;width:auto !important}}@media (min-width:767px) and (max-width:1023px){.pafe-sticky-header-fixed-start-on-tablet{position:fixed !important;top:0;width:100%;z-index:99}.pafe-display-inline-block-tablet{display:inline-block;margin-bottom:0;width:auto !important}}@media (min-width:1024px){.pafe-sticky-header-fixed-start-on-desktop{position:fixed !important;top:0;width:100%;z-index:99}.pafe-display-inline-block-desktop{display:inline-block;margin-bottom:0;width:auto !important}}@media (min-width:766px){.pafe-display-inline-block-mobile{display:inline-block;margin-bottom:0;width:auto !important}}@media (max-width:766px){.pafe-display-inline-block-mobile{display:inline-block;margin-bottom:0;width:auto !important}}@media (min-width:767px) and (max-width:1023px){.pafe-display-inline-block-tablet{display:inline-block;margin-bottom:0;width:auto !important}}@media (min-width:1024px){.pafe-display-inline-block-desktop{display:inline-block;margin-bottom:0;width:auto !important}}

GENERAL INFORMATION

ACTIVITIES OF DAILY LIVING (Check Appropriate Boxes):

COOKING/EATING

BATHING/HYGIENE

MOBILITY

DRESSING / GROOMING

MEDICATION ASSISTANCE

MEAL LOG

For Display Only