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  • Do you have difficulty walking, getting in and out of your chair, bed, or automobile?

  • Do you have difficulty with showering or bathing, meal preparation, toileting, cleaning, or doing laundry?

  • Have you recently received a doctor's order for a walker, cane, wheelchair, or other safety equipment?

  • Do you have difficulty keeping your balance or standing for long periods of time?

  • Have you fallen recently or repeatedly?

  • Do you feel weak and uninterested in doing things that you used to enjoy?

  • Have you recently been prescribed oxygen therapy?

  • Have you recently been hospitalized or experienced multiple hospitalizations?

  • Do you have unresolved pain of any kind?

  • Do you have wounds or skin problems that do not heal easily?

  • Are you having trouble with your hands, feet, hips, shoulders, or knees?

  • Are you having challenges with any of your medications or taking them as ordered?

  • Have you recently been diagnosed with Diabetes or having trouble with keeping your Diabetes under control?

  • Do you experience difficulty breathing when trying to perform usual daily tasks?

  • Do you need to see your doctor but have been unable to get to his or her office?


Patient Checklist

If you answered yes to any of the above questions or are concerned about any of the above issues concerning a loved one, please contact our office about how we may be able to help.

Answer YES for NO to the following questions:


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