Last Name *

First Name *

Middle Initial

Phone Number *

Gender *

Male Female

What is your age group? *

Younger than 65 years 66-75 years Over 75 years

What equipment do you use to help with walking? *

None

Cane

Walker or crutches

Will you live with someone who can care for you after discharge? *

Yes

No

Do you use community supports, such as home help, Meals on Wheels, or nursing care? *

None or 1 per week

2 or more times per week

How far can you walk on average? *

2 blocks or more

1-2 blocks

Housebound