*Denotes required field

Do you live alone or are you often home alone?*

YesNo

Do you shower in your bathtub?

YesNo

Have you ever slipped or fallen in your bathroom, bedroom or on your stairs?

YesNo

Are you ever dizzy or light-headed? Or do you take medication that could make you drowsy?

YesNo

Do you have mobility issues that make you unsteady on your feet?

YesNo

Do you have pain or numbness that makes walking difficult?

YesNo

Are you sometimes worried that you could have a heart attack or stroke when you are alone?

YesNo

Do you wake up and go to the bathroom in the dark of the middle of the night?

YesNo

Are you concerned about being trapped in your home by a fire?

YesNo

Are you concerned you won’t be able to reach your phone to call for help if you need assistance? Or that you might be too out-of-breath or in too much pain to call?

YesNo

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