01About Your Loved One
What is their age range?
What is their current living situation?
Any current diagnoses or health conditions? (select all that apply)
Are there any cognitive concerns?
02Recent Health & Safety Changes
Any falls in the past 6 months?
Any recent hospitalizations or surgeries?
Any noticeable decline in strength, balance, or mobility?
03Mobility & Daily Activities
Do they use an assistive device?
Where are they having difficulty? (select all that apply)
Do they experience dizziness, weakness, or unsteadiness?
04Home Environment
What type of home do they live in?
Any safety equipment already installed? (select all that apply)
Which area of the home feels most unsafe? (select all that apply)
05Caregiver Support
Who currently provides care?
For caregivers & family members: Do you have concerns about safely assisting your loved one with movement or daily tasks?
06Your Goals & Concerns
What is your biggest safety concern right now? (select all that apply)
How did you hear about us?
