Risk Assessment and Prediction Form
Date Form Completed
Date of Proposed Surgery
What is your age group?
Younger than 65 years
Over 75 years
Patient Instructions: Please select the answer that best matches you.
What equipment do you use to help with walking?
Walker or crutches
Will you live with someone who can care for you after discharge?
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
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