Safety and Independence Survey
Please answer the following questions to help us assess your safety and independence levels.
How safe do you feel in your current living environment?
1
1
2
3
4
Best
5
1 is , 5 is Best
How confident are you in performing daily tasks independently?
2
1
2
3
4
Best
5
1 is , 5 is Best
Do you use any assistive devices (e.g., walker, cane, wheelchair)?
Option 1
Option 2
Option 3
If yes, please specify which assistive devices you use.
Do you require assistance with any daily activities?
Option 1
Option 2
Option 3
If yes, please specify the type of assistance needed.
Submit
Should be Empty: