Quiz - Rapid Screen©

To take the quiz, answer each question by selecting the appropriate check box. Click on the "Step 1. Calculate" button to total your score. Print a copy of your results for your records by clicking on the "Step 2. Print to PDF " button. Clicking on "Step 3. See How You Scored on the Quiz" will show you how you may or may not be at risk. Take the quiz a minimum of once per year or again if something in your life changes.

Date: 8/1/2010

Name:

1.	Do you need help to do the following? Walking Getting out of bed/chair Going to the bathroom Bathing Dressing Eating	0
2.	During the last 6 months, have you had a fall that caused injuries? Yes No 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? Yes No	0
4.	Does your caregiver feel overwhelmed or stressed because of the care they provide you? Yes No	0
5.	Have you thought about moving to other housing? Yes No	0
6.	Do you live alone? Yes No	0
7.	Do you or your family have concerns about your memory, thinking, or ability to make decisions? Are you: Very Concerned Somewhat Concerned Not Concerned	0
TOTAL SCORE =		0

SK Rev. 071114