* = Required Information

QUESTION 1:


Alzheimer’s/Dementia/Confusion
Diabetes
Stroke
Heart failure or other heart conditions
COPD or other respiratory conditions
Cancer

QUESTION 2:


Joint replacement or surgery (i.e. hip, shoulder, knee, etc.)
Falls, dizziness, or loss of balance
Amputation
Serious illness (i.e. flu, pneumonia, infection)
Depression

QUESTION 3:


Yes No Not Sure

QUESTION 4:


Insulin or oral diabetic medication
Coumadin/Warfarin (anti-clotting/blood thinner)
IV Medication
Pain Medication
Oxygen
Dialysis
Other

QUESTION 5:


Frequently - Several times a month
Regularly - At least once a month
Sometimes - A few times a year
Rarely - Once a year or less
Don’t know

QUESTION 6:


Using the restroom
Preparing meals
Bathing
Getting dressed
Shopping for groceries
Driving

QUESTION 7:


Frequently - Several times a month
Regularly - At least once a month
Sometimes - A few times a year
Rarely - Once a year or less
Don’t know

QUESTION 8:


They have no trouble leaving their home.
They have some trouble leaving their home, but not enough to keep them from going somewhere.
They use a wheelchair, walker, or need someone else’s assistance to leave their home.
A lot of effort is required for them to leave their home, which exhausts them. They rarely and briefly leave home because of this difficulty.
Their condition makes it difficult or even impossible to leave their bed

QUESTION 9:

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