Do you live alone?

  (If the answer to #1 is "No") Are there periods of the day or week when your caregiver is away, and you are alone?

  Have you fallen inside or outside your residence at least one time during the past 3 years?

  Are there times when you feel weak and dizzy?

  Are you worried that you may fall and not be able to call for help?

  Do you worry about taking a shower and bath alone?

Do you have one or more of these ailments? (Check all that apply)

  Arthritis

  Chronic Obstructive Pulmonay Disease (COPD)

  Congestive Heart Failure

  Diabetes

  Hypertension or High Blood Pressure

  Low vision or Visually Impaired

  Osteoporosis

  Stroke

  Are you concerned that you may have a reaction to medication and not be able to get help?
(example: insulin)

  Were you hospitalized or taken to the emergency room during the past 2 years?

 Do you use a cane, walker, wheelchair, stairclimber, or other device to help you balance or walk?

 Are you afraid that someone might hurt you physically or break into your home?

 Do you feel unsafe in your neighborhood?

How much difficulty do you currently have bending over from a standing position to pick up something without having to hold onto anything?

I can't! A lot! Sometimes None

How much difficulty do you currently have carrying something in your arms while climbing stairs? (Laundry basket, etc)

I can't! A lot! Sometimes None

How much difficulty do you currently have walking up or down inclines?

I can't! A lot! Sometimes None

How difficult is it to walk several blocks without assistance of some kind?

I can't! A lot! Sometimes None

How difficult is it for you to stand up from a soft couch?

I can't! A lot! Sometimes None

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