DEMOGRAPHIC INFORMATION

INDEPENDENCE & WELLNESS ASSESSMENT

I take all medications at the correct time and dosage as prescribed.
I can safely get in and out of a chair, shower, and bed without help
I prepare or plan balanced, nutritious meals at least 5 days a week.
I remember appointments, medications, and important tasks without reminders.
I have social contact with friends or family at least once a week (in person, phone, or video).
I get at least 20 minutes of walking, stretching, or light exercise on most days.
I feel confident navigating my home safely without risk of falling
I have recently been hospitalized
I feel emotionally well and generally satisfied with life
I complete routine tasks like cooking, cleaning, or laundry without help.

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