1. Do you need a healthcare provider’s regular care to manage your health?  

2. Have you been to the hospital or emergency room more than once recently?  

3. Do you have health issues such as stroke, lung or heart disease, or diabetes?    

4. Do you have regular feet swelling?  

5. Do you have trouble leaving home or walking?  

6. Do you have shortness of breath with little activity?  

7. Do you experience trouble with bathing or getting around?  

8. Have you had changes to medication recently?  

9. Do you take multiple medications each day?  

10. Are you confused about how to take medication?  

11. Have you fallen in the past year?  

12. Have you had a fall that resulted in a skin injury, broken bone or head injury?  

13. Have you gained or lost an unusual amount of weight in a short time?