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| First of all, how would you evaluate the hospitals in your area in their ability to treat health problems related to age? |
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| How would you evaluate your overall health. Would you say you are: |
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| What about the amount of social support you receive from your family, friends, and the like. When you have the need to talk to someone or go on outings with friends and/or relatives, do you feel there is someone who fulfills these needs? |
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| How often does a close friend or relative visit you in your home? |
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| Which of the following best describes your capacities to perform everyday activities: |
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| Can you get to places out of walking distances: |
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| Can you go shopping for groceries: |
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| Can you prepare your own meals? |
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| Can you manage your own money? |
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| Do you dress and undress yourself? |
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| During the past 24 hours, how many different kinds of medication have you taken? |
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| If you have taken medication in the last 24 hours, how many of them have been prescribed by your physician? |
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| If you have taken medication in the last 24 hours, do you take your medicine |
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| Do you experience chronic pain? (That is, ongoing or recurring pain) |
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| If yes, how are you currently being treated for chronic pain? |
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| Number of members residing in your household: |
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Have you dropped many of your activities and interests?
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Are you afraid that something bad is going to happen to you?
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| Do you prefer to stay at home, rather than going out and doing new things? |
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Do you feel full of energy?
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Bathing with sponge, bath, or shower
how do you grade yourself |
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| Transferring (in and out of bed or chair) |
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