I live alone No Yes

My physical condition does not permit me to care for myself and do the things I was able to do before No Yes

My family is unable to care for all my needs No Yes

My doctor has prescribed a special diet No Yes

I have difficulty selecting and preparing my own meals No Yes

I don't understand my disease and how to control it No Yes

I have more than one medical problem No Yes

I take many prescription medicines No Yes

My doctor has prescribed some new medicines, which I have never taken before No Yes

My physical limitations may require me to learn to use a wheelchair, walker or other assistance devices to manage at home No Yes

I have been in the hospital twice in the last six months No Yes

I have had visits to my home by a nurse or other health care professional in the past No Yes

I am homebound, making it difficult to do errands, etc No Yes

I have trouble-bathing myself NoYes

Your EMail Address: 

Your Phone Number:  

Your Name: