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