* Name

* Email

* Phone

Have you experienced any weight loss in the last 6 months due to your illness? Have you experienced any weight loss in the last 6 months due to your illness? Yes No

Do you spend the majority of your day in the bed or a chair? Do you spend the majority of your day in the bed or a chair? Yes No

Is it a struggle to do the activities of daily living such as: dressing yourself, bathing, feeding yourself or using the bathroom on your own? Is it a struggle to do the activities of daily living such as: dressing yourself, bathing, feeding yourself or using the bathroom on your own? Yes No

Please explain

Have you fallen two times in the last six months? Have you fallen two times in the last six months? Yes No

Please explain

Have you been to the emergency room or hospital two times in the last six months? Have you been to the emergency room or hospital two times in the last six months? Yes No

Please explain

Has a Dr. diagnosed you with any serious illness such as: cancer, COPD, heart failure, parkinsons disease, kidney disease, dementia, liver disease or ALS? Has a Dr. diagnosed you with any serious illness such as: cancer, COPD, heart failure, parkinsons disease, kidney disease, dementia, liver disease or ALS? Yes No

Please explain

Do you require assistance or help to get to and from your Dr. appointments? Do you require assistance or help to get to and from your Dr. appointments? Yes No

Please explain