Home Assessment Pre Visit Questionnaire

Full Name*

First NameLast Name

Gender*

MaleFemale

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Date of Birth*

MonthDayYear

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?

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?

Please list the types of exercise you do regularly

Do you have any difficulty with the following:

Additional information you want to share?

PRE VISIT QUESTIONNAIRE

GENERAL INFORMATION

Understanding your unique healthcare needs.

HOME ENVIRONMENT