Care Recipient Form

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    Personal information
    Health
    • YesNo
    • CHF (Congestive Heart Failure)COPD (Chronic Obstructive Pulmonary Disease)Macular Degeneration Multiple Sclerosis Cerebral Palsy Parkinson's Disease EpilepsyLupusRheumatoid ArthritisKidney DiseaseCancer
    • CaneWalkerWheelchairHearing AidsOxygen
    • YesNo
    • CigarettesPipeOther
    • Must abstain while Mentor is present.
    • DogsCatsBirds
    • YesNo
    • Causeway Caregivers performs a background check under the direction of The Aging and Disability Resource Center of La Crosse County on all mentors, caregivers and care recipients to determine eligibility.
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