Free Medical Monitoring Assessment

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

Yes
No

Do you shower in your bathtub?

Yes
No

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

Yes
No

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

Yes
No

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

Yes
No

Do you have pain or numbness that makes walking difficult?

Yes
No
Third Choice

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

Yes
No
Third Choice

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

Yes
No

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

Yes
No

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?

Yes
No

Name *

First

Last

Email

Phone