Self-Assessment Questionnaire


  1. Have you fallen recently?
    Yes     No
  2. Are you concerned about the risk of falling?
    Yes     No
  3. Do you find yourself forgetting to take medication, or forgetting to complete tasks that were once simple to remember?
    Yes     No
  4. Do you experience memory loss or forgetfulness?
    Yes     No
  5. Does your chronic illness require constant monitoring?
    Yes     No
  6. Have you recently needed to visit the emergency room?
    Yes     No
  7. Have you been hospitalized in past three months?
    Yes     No
  8. Would professional assistance help make you manage your chronic medical condition?
    Yes     No
  9. Do you need immediate assistance in giving yourself the care that you require?
    Yes     No
  10. Do you currently require occupational therapy?
    Yes     No
  11. Do you currently require physical therapy?
    Yes     No

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In this section you'll find information about how you can continue to live an active, independent and healthy life.