Activities of Daily Living/Safety Questions

Some of these questions might seem ridiculous to you, but please bear with us. This is a standard questionnaire for older patients.

Are you able to bathe/shower without assitance?YesNo
Are you able to go to the bathroom without assitance?YesNo
Are you able to dress yourself without assistance?YesNo
Are you able to go shopping without assitance?YesNo
Are you able to use the phone without assitance?YesNo
Are you able to drive a car?YesNo
Are you able to handle and schedule your own medications?YesNo
Are you able to handle your own money and balance your checkbook?YesNo
Does your home have adequate lighting in stairways/hallways?YesNo
Do you have working smoke detectors in your home?YesNo
Do you have a carbon dioxide monitor near your bedroom?YesNo
Do you have an escape plan in case of fire?YesNo
Do you handrails on stairs inside and outside your home?YesNo
Do you have a mat in your shower to prevent slipping?YesNo
Do you have many throw rugs in your home (these increase the risk of tripping/falling)?YesNo
Have you fallen in the past 6 months?YesNo
Do you have any trouble remembering important things in your life (forgetting where you put your keys doesn't count!)?YesNo
Do you have any trouble with your vision that is not corrected by glasses?YesNo
Do you have significant problem with your hearing?YesNo



Please list any other medical providers you see (including dentists, eye doctors, cardiologists, dermatologists, etc):