How easily do you get around?

I use a cane, walker, or wheelchair.

I need help from another person sometimes.

I cannot move around without another person's help.

How often do you fall?

Sometimes, but I can get up on my own.

Sometimes, and I need help getting up.

Often, and I cannot get up on my own.

I drive or take public transit on my own.

I can travel on my own but need help arranging rides.

I would like someone to arrange rides and come along.

I need a ride to every appointment and errand.

I need help getting to the dining room.

I handle it on my own, but sometimes I need a reminder.

I need someone nearby for safety.

I manage incontinence on my own with supplies that help.

I sometimes need help managing incontinence.

I need hands-on help with bathroom use and incontinence.

None. I schedule and keep them on my own.

I can keep appointments, but need help scheduling them.

I need someone to schedule and take me to appointments.

None. I take everything on my own.

I need help measuring doses or applying medications.

I need someone to manage my medications for me.

I know where I am, who people are, and what day it is.

I forget names, dates, or the time of day.

I have trouble remembering recent events.

I often do not recognize people, places, or time.

I cope with stress well and enjoy being around others.

I prefer to be alone most of the time.

I often feel frustrated, anxious, or agitated and need support.

I arrived somewhere and could not remember how I got there.

I took much longer than usual to come home from a walk or drive.

I felt I needed to be somewhere else even though I was home.

I could not remember directions to a familiar place.

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