DEMOGRAPH INFORMATION

First Name *

Date of birth *

Email *

Sex *

Male

Female

HOME ASSESSMENT

Personal Care (Daily Living) *

I can manage bathing, dressing, and toileting safely without help

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Caregiver Coverage *

My family/friend support is reliable and not strained

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Living Situation/Supervision *

I have someone available to help me when I need it

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Transportation / Community Access *

I can reliably get to appointments and run errands without help

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Home Safety Environment *

My home is set up safely (lighting, clutter, bathroom safety, stairs/handrails)

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

INDEPENDENCE ASSESSMENT

Medications *

I take all medications at the correct time and dosage as prescribed.

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Mobility *

I can safely get in and out of a chair, shower, and bed without help

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Meals *

I prepare or plan balanced, nutritious meals at least 5 days a week.

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Memory *

I remember appointments, medications, and important tasks without reminders.

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Social *

I have social contact with friends or family at least once a week (in person, phone, or video).

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Exercise *

I get at least 20 minutes of walking, stretching, or light exercise on most days.

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Falls *

I feel confident navigating my home safely without risk of falling

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Hospitalization *

I have recently been hospitalized

1 Month
3 Months
6 Months
12 Months
Over 2 Years
No elements found. Consider changing the search query.
List is empty.

Emotions *

I feel emotionally well and generally satisfied with life

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

Tasks *

I complete routine tasks like cooking, cleaning, or laundry without help.

Never
Rarely
Sometimes
Usually
Always
No elements found. Consider changing the search query.
List is empty.

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