| 1. |
Are you alone for several hours of the day or night? |
Yes No |
| 2. |
In the past 12 months, have you experienced a fall or have you been afraid of falling in your home? |
Yes No |
| 3. |
In the past 12 months, have you been to the emergency room or hospitalized? |
Yes No |
| 4. |
Do you suffer from any of these chronic medical conditions (heart disease, stroke, COPD, osteoporosis, diabetes, arthritis)? |
Yes No |
| 5. |
Do you use a walker, cane, wheelchair, stair climber or other devices to assist you in balancing or walking? |
Yes No |
| 6. |
Do you take several daily medications? |
Yes No |
| 7. |
Do you have trouble, or need assistance, with any of these daily activities (bathing, dressing, meal preparation, toileting, etc...)? |
Yes No |
| 8. |
If you had a medical alert service, would it provide you or your loved ones peace of mind when you are alone? |
Yes No |
| 9. |
Do you think that living independently is an important factor in your quality of life? |
Yes No |
| Review your total score with the assessment below. |
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