Do you have trouble preparing meals or eating independently?

Do you need help getting dressed or choosing appropriate clothes?

Do you struggle with bathing or showering safely?

Do you have difficulty grooming (hair, shaving, nails)?

Do you need reminders or assistance with toileting or managing incontinence?

Do you have trouble preparing meals or eating independently?

Are you able to take your medications correctly without help?

Do you need assistance with housekeeping or laundry?

Is it becoming harder to move around your home safely (walking, transferring from bed/chair)?

Have you had any recent falls or near-falls in the last 6 months?

Do you worry about being alone in case of an emergency?

Do you feel your current home is no longer safe for you?

Have you been hospitalized or visited the ER in the past 12 months due to a fall, medication issue, or forgetfulness?

Do you manage your chronic health conditions (diabetes, heart disease, etc.) well on your own?

Do you ever forget to eat or drink enough during the day?

Are you sleeping well, or do you have frequent sleep disturbances?

Do you frequently misplace items or forget where you put things?

Do you sometimes get lost or confused when driving or walking in familiar places?

Do you have trouble remembering appointments, bills, or important dates?

Have family members expressed concern about your memory?

Do you repeat questions or stories in conversation?

Are you still able to manage your finances and pay bills accurately?

Do you often feel lonely or isolated at home?

Have you stopped participating in hobbies or activities you used to enjoy?

Do you find it difficult to get out of the house for social visits or errands?

Are you eating regular, nutritious meals?

Do you feel anxious or depressed more often than before?

Would you enjoy having more opportunities to socialize with peers?

Do you currently have family or friends helping you regularly?

Is your family caregiver feeling overwhelmed or burned out?

Are you worried about becoming a burden to your loved ones?

Has your spouse or partner expressed difficulty keeping up with caregiving demands?

Do you live alone, or is there someone available 24/7 if needed?

Are you open to the idea of moving to a community where help is available if you need it?

Would you like to maintain your independence while having support nearby?

On a scale of 1–5, how concerned are you about your current living situation and safety?

(1 = not concerned, 5 = extremely concerned)