|
| Check all Fields that Apply: |
|
|
|
Lives alone or left alone for extended periods by caregiver
|
|
|
|
Alone for extended periods of time
|
|
|
|
Have a least one chronic illness (heart disease, stroke, diabetes, pulmonary issues,
osteoporosis, arthritis)
|
|
|
|
Feels nervous to be alone due to a medical concern or unsafe living environment
|
|
|
|
Uses mobility assisted devices (Walkers, canes, crutches, wheel chair etc.)
|
|
|
|
Requires assistance performing activities of daily living (walking, bathing, toileting,
preparing meals etc.)
|
|
|
|
Physical or sensory impairments (Vision, hearing, walking etc.)
|
|
|
|
History of falls or medical emergencies
|
|
|
|
Hospitalized within last 12 months
|
|
|
|
History of medication management problems
|
|
