PRE VISIT QUESTIONNAIRE
Please answer the following questions so we can best serve your needs. It should take approximately 10 minutes to complete.
GENERAL INFORMATION
Full Name
*
First Name
Last Name
Gender
*
Male
Female
E-mail
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
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2015
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Year
What are the main reasons you are seeking a home assessment?
*
I have a history of falls.
I am being discharged from the hospital soon.
I have been diagnosed with a progressive disease.
I'm working with an architect or builder and I need recommendations for aging in place.
I'm interested in disease and injury prevention.
I'm having trouble navigating in my home or community.
Other
What are your goals for the home and health assessment?
Understanding your unique healthcare needs.
How do you rate your current level of health?
Have you fallen in the past year? If so, how many times? Where were you when the fall(s) occurred?
Please list any medical diseases/conditions you have been diagnosed with by your doctor.
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
Please list any prescribed medications you are currently taking (e.g. warfarin, laxatives)
Do you exercise?
Never
1-2 times a week
3-4 times a week
5-6 times a week
Everyday
Please list the types of exercise you do regularly
Do you have any difficulty with the following:
dressing
bathing
meal prep
housekeeping
medication management
Additional information you want to share?
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HOME ENVIRONMENT
Now that we've learned a little about you, tell us about your home.
What type of home do you live in?
single family home - single level
single family home - multi level
townhouse
condo/apartment
Do you have stairs to enter or navigate within your home?
Please Select
No
Yes, to enter
Yes, inside the home
Yes, both to enter and inside the home
Do you have access to a bathroom on the main level of your home?
No
Yes - powder room
Yes - full bath
Do you have grab bars in your bathroom?
Please Select
No
Yes - shower area
Yes - toilet area
yes - shower and toilet area
Where do you spend most of your time in your house?
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Finish
Should be Empty: