* = Required Information

Question 1


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

Question 2


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

Question 3

Yes Not Sure No

Question 4


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


Bathing
Getting dressed
Preparing food
Using the restroom
Grocery Shopping
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


Their condition makes it very difficult or impossible to even leave bed.
Leaving home requires a lot of effort that exhausts them. They leave home infrequently and briefly because of the difficulty.
They use a walker, wheelchair, or require another person’s help to leave home.
They have some difficulty leaving home, but not enough to stop them from going somewhere.
They have no difficulty leaving home.

Question 9

Security code