During the last 4 weeks, how much have you been bothered by feeling anxious, depressed, irritable, sad, downhearted or blue?
During the past 4 weeks, has your physical and emotional health limited your social activities with family, friends, neighbors or groups?
During the past 4 weeks, how much bodily pain have you generally had?
During the past 4 weeks, was someone available to help you if you needed and wanted help?
During the past 4 weeks, what was the hardest physical activity you could do for at least 2 minutes?
Can you get to places out of walking distance without help?
Can you go shopping for groceries or clothes without someone's help?
Can you prepare your own meals?
Can you do your housework without help?
Because of any health problems, do you need the help of another person with your personal care needs such as eating, bathing, dressing, or getting around the house?
Can you handle your own money without help?
During the past 4 weeks, how would you rate your health in general?
Are you having difficulties driving your car?
Do you always fasten your seat belt when you are in a car?
How often in the past 4 weeks have you been bothered with falling or dizzy when standing up?
How often in the last 4 weeks have you been bothered by sexual problems?
How often in the past 4 weeks have you been bothered by trouble eating well?
How often in the past 4 weeks have you been bothered by teeth or denture problems?
How often during the past 4 weeks have you been bothered by problems using the telephone?
How often during the last 4 weeks have you been bothered by Tiredness or fatigue?
Have you fallen two or more times in the past year?
Are you afraid of falling?
Are you a smoker?
During the past 4 weeks, how many drinks of wine, beer, or other alcoholic beverages did you have?
Do you exercise for about 20 minutes three or more days a week?
Have you been given information to help you with hazards in your home that might hurt you?
Have you been given information to help you with keeping track of your medications?
How often do you have trouble taking medicines the way you have been told to take them?
How confident are you that you can control and manage most of your health problems?
Please list the Specialists that are caring fo you.
Are you worried about your memory?
Have you had any recent immunizations?
Do you have a living will or advanced directive? (If you have one, please bring a copy)
Have you had any preventive tests done recently? (Such as blood work, mammogram, Xrays)
