Quiz - Older Adults

Instructions:  Answer the 7 questions by clicking on the appropriate check box.  To total your score, click on "Step 1. Calculate."  To print your quiz, click on "Step 2. Print to PDF." To view your results, click on "Step 3. See Your Quiz Results."

To print a blank quiz, click on "Print Blank Quiz."

Date: 12/16/2017

Name:

1.
Do you need help to do the following?





0
2.
During the last 6 months, have you had a fall that caused injuries?

NOTE: “Injuries” means fracture or joint dislocation, head injuries resulting in loss of consciousness and hospitalization, joint injuries that led to decreased activity, internal injuries that led to hospitalization, OR 3 or more of any falls
0
3.
Do you have a family member/friend give you help when you need it?

0
4.
Does your caregiver feel overwhelmed or stressed because of the care they provide you?

0
5.
Have you thought about moving to other housing?

0
6.
Do you live alone?

0
7.
Do you or your family have concerns about your memory, thinking, or ability to make decisions?
Are you:

0
TOTAL SCORE = 0