Are you a veteran?

Yes

No

Was your spouse a veteran?

Yes

No

In the past 12 months, have you been a patient in a hospital where you stayed overnight?

0

1 Time

2 Times or more

In the past 6 months, how many times did you go to the emergency room at hospital?

0

1 time

2 times or more

Have you had surgery in the past 12 months?

Yes

No

How many prescription medications do you take?

None

1-5

6 or more

Have you ever smoked cigarettes, a pipe or cigars, or chewed tobacco?

Yes

No

Are you currently smoking or using tobacco?

Yes

No

If you are currently smoking tobacco, would you like assistance to stop using tobacco?

Yes

No

Do you exercise or do moderate physical activity such as walking 5 days a week?

Yes

No

Have you had any problems with balance or walking in the past 12 months?

Yes

No

How many falls have you had in the past year?

None

1-2

More than 3

Many people experience problems with urinary incotinence, the leakage of urine.

In the past 6 months, have you accidentally leaked urine?

Yes

No

If yes, would you like to discuss treatment options?

Yes

No

Are you being treated for depression with medication?

Yes

No

Have you ever attempted to commit physical harm on yourself?

Yes

No

Other pertinent information that would be useful for the RCFE to know.

***Disclaimer: This document is for informational purposes only. It 's intent, is to provide additional information to the RCFE and not medical in nature. Stafford Senior Solutions is not a doctor or licensed in medical. All answers were provided by either the resident or family members. Information and answers to the proceeding questions, should be verified by a medical assesment or consulted with a physician.

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