Home Assessment Pre Visit Questionnaire

Full Name

First NameLast Name

Gender

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?

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