|
1. |
Is the person alone for several hours during the day and/or night? |
|
|
|
|
2. |
Has the person fallen, been worried about falling, or otherwise been at risk of falling in the home
during the past year? |
|
|
|
|
3. |
Is it important to this person to continue living independently at home? |
|
|
|
|
4. |
Has the person been hospitalized or been to the emergency room during the past year? |
|
|
|
|
5. |
Does the person use a cane, walker, wheel chair or other assistive device to help with walking or balance? |
|
|
|
|
6. |
Does the person suffer from one or more of these ailments?
|
• |
Osteoporosis |
|
• |
Arthritis |
|
• |
Diabetes |
|
• |
Chronic Obstructive Pulmonary Disease (COPD) |
|
• |
Heart Failure |
|
• |
Stroke |
|
• |
Continues
Falling |
|
|
|
|
|
7. |
Does the person take several prescription medications on a daily basis? |
|
|
|
|
8. |
Does the person need assistance with at least one of the following activities?
|
• |
Dressing |
|
• |
Grooming |
|
• |
Meal preparation |
|
• |
Eating |
|
• |
Toileting |
|
• |
Bathing |
|
|
|
|
|
9. |
As a caregiver, is it becoming difficult for you to find time for yourself? |