⏱Complete in one session
1
Your Info
2
Parent Residence
3
Parent Info
4
Preventive Care
5
Support & Team
6
Declaration
Welcome to Samarth
Let's build your parent's
care plan together
care plan together
This form helps us understand your family's situation so our Care Counsellor can prepare a truly personalised plan. There are no wrong answers. If you're not sure about something, just say so. We'll work it out together on the first call.
Takes about
8–10 minutes
Your data is
Private & secure
Your information
You'll be the primary point of contact for Samarth.
Title Required
First name Required
Last name
Email address Required
We'll send your care plan summary here
Your mobile number Required
Include country code (many of our families are based overseas)
Your address Required
Country Required
Choose a country code first to narrow the list.
State / Province
City
PIN / Postcode Required
Step 1 of 6
Parents' residence
Where your parents currently live. Our Care Counsellor will visit this address.
This address is used to assign your local care team and to conduct the home safety audit on the first visit. Parents' care is always delivered in India.
Address line 1 Required
Address line 2 Optional
Country
State Required
City Required
PIN code Optional
Can be filled later if not known
Home landline Optional
Step 2 of 6
Parents' information
Health profile and details for each parent we'll be caring for.
A note from our Care team: It's completely normal not to know every detail, especially if you're not living with your parents. Fill in what you know, mark "Not sure" wherever you need to. Our Care Counsellor will fill the gaps on the first call. Nothing here is a test.
Parent 1
+ Add second parent
Title
First name Required
Last name Required
Mobile number Required
10-digit Indian number, must differ from your mobile
Email address Optional
Date of birth
Health conditions
Select only what has been formally diagnosed. Selecting "Not sure" is perfectly fine.
Hypertension
Diabetes
Arthritis
Cataract
Heart disease (CVD)
Lung disease
Digestive disease
Osteoporosis
Kidney disease
Liver disease
Cancer
Anxiety
Depression
Dementia / memory loss
Parkinson's disease
Alzheimer's disease
Other
Not sure: discuss on call
Functional & cognitive capacity Required
Hobbies & interests
Helps us suggest activities that bring joy and engagement. Select anything that feels right.
Dance
Painting
Writing
Photography
Gardening
Cooking
Political discussion
Drawing
Pottery
Music
Knitting
News / general knowledge
Sports discussion
Games (chess / cards)
Movies
Reading books
Bhajans / prayers
Tours / outings
Other
All the same questions as Parent 1. Skip anything you're not sure about. You can always update this later.
Title
First name Required
Last name
Mobile number Required
Same number as Parent 1
Email address Optional
Date of birth
Health conditions
Hypertension
Diabetes
Arthritis
Cataract
Heart disease (CVD)
Lung disease
Digestive disease
Osteoporosis
Kidney disease
Liver disease
Cancer
Anxiety
Depression
Dementia / memory loss
Parkinson's disease
Alzheimer's disease
Other
Not sure: discuss on call
Functional & cognitive capacity
Hobbies & interests
Dance
Painting
Writing
Photography
Gardening
Cooking
Political discussion
Drawing
Pottery
Music
Knitting
News / general knowledge
Sports discussion
Games (chess / cards)
Movies
Reading books
Bhajans / prayers
Tours / outings
Other
Step 3 of 6
Preventive healthcare
Our medical expert will review all of this with your parents on the first visit.
Why we ask: Knowing what's already been done helps our doctor focus on what genuinely matters in the first review, not repeat work already covered. Mark "Not sure" freely, it's very helpful too.
Screenings already completed
Lipid profile ?Blood test measuring cholesterol levels. Assesses heart disease and stroke risk.
Lipid / cholesterol disorder
Blood sugar (HbA1c) ?3-month average blood glucose level, screens for and monitors diabetes.
Diabetes screening
ECG ?Electrocardiogram. Records heart electrical activity to detect rhythm issues.
Cardiovascular screening
Bone density test ?DEXA scan. Measures bone strength to detect osteoporosis and fracture risk.
Osteoporosis screening
CEA blood test ?Carcinoembryonic Antigen. Blood marker to screen for colorectal cancer.
Colorectal cancer screening
PSA test (men only) ?Prostate-Specific Antigen. Screens for prostate cancer.
Breast cancer screening (women only)
Vaccinations already completed
Influenza (annual flu shot)
Pneumococcal
Protects against pneumonia
Shingles vaccine ?Recombinant Zoster Vaccine (Shingrix). Recommended for adults 50+. Prevents shingles rash and nerve damage.
Recommended for adults 50+
Tetanus / Diphtheria (Td)
Booster recommended every 10 years
Measles, Mumps, Rubella (MMR)
Home safety concerns Optional
We conduct a mandatory home safety audit on the first visit. Flag any specific concerns here so we come prepared.
Step 4 of 6
Key support areas & care team
What to focus on first, emergency details, and who else should be kept informed.
What should we focus on first
The best care enhances quality of life, not just manages problems. Select all that apply. You can also add a note below.
🏥 Hospital visits & medical support
💊 Medical help at home
📱 Help using technology
💬 Communication (WhatsApp, calls)
🎬 Entertainment (YouTube / Netflix)
🛒 Useful services (Uber, banking, shopping)
🌳 Outdoor activities & social outings
🎲 Indoor activities & games
🔧 House maintenance & errands
Anything else to tell us? Optional
Emergency hospital
Hospital name Optional
You can add this later if not decided yet
Hospital address Optional
Do parents have house help at home?
Care team
Add siblings, spouse, or other family members who will be given access to the Samarth app. They will be able to receive updates, interact, and make requests on behalf of your parents. You can also do this later.
Add a care team member?
Step 5 of 6
Declaration
Almost done. Two quick confirmations and you're set.
Please read and confirm the following:
Privacy & data: Your information will be stored securely and used only to build and manage your care plan. We will never share it with third parties without your consent. Read our Privacy Policy →
Working environment: To the best of your ability, you will provide a safe working environment for the Care Counsellor and service providers. Any cognitive conditions have been declared above, and the residents have no communicable disease. You agree to treat all Samarth staff with courtesy and respect, and to give advance notice if a scheduled visit needs to be rescheduled.
✓
✓
I confirm that we will provide a safe and respectful working environment for the Care Counsellor and all service providers *
Step 6 of 6
🌿
You're all set.
Thank you for taking the time. Your care plan is now being prepared. Here's what happens next.
