Do you live alone No Yes

Do you use assistant devices, such as a walker, cane or wheelchair? No Yes

Have you been hospitalized in the past year? No Yes

If yes to hospitalized, how many times? 1 2 3 4 5 or more

If yes to hospitalized, what was the reason admitted: Type reasons Hospitalized here

Do you take prescription medicines? No Yes

Do you need someone to help with bathing, dressing, walking or eating? No Yes

Do you feel socially isolated? No Yes

Can you easily do all the things you need around the house, like cooking, cleaning, laundry and shopping? No Yes

Have you made advanced directives about how you want to be cared for if you are unable to speak for yourself? No Yes

Does your medical condition change rapidly or is it severe that you require someone to check on you? No Yes

Have you reviewed your home and removed all safety hazards? No Yes

Do you have problems with memory or judgment? No Yes

Are you losing weight? NoYes

Do you have difficulty moving around or feel unsure of yourself? NoYes

Is it hard for you to bathe or dress yourself? NoYes

Can you cook full meals for yourself everyday? NoYes

Can you do your own laundry? NoYes

Do you have trouble finding transportation to the places you want to go? NoYes

Do you worry a lot about how you are going to take care of/maintain your house? NoYes

Do you want to know more about services that could help you stay at home? NoYes

Your EMail Address: 

Your Phone Number:  

Your Name: