How would you describe your loved one's mobility?
Completely independent, walks without assistance
Mostly independent, occasional use of cane or walker
Needs assistance with walking, frequent falls or balance issues
Uses wheelchair or needs significant mobility support
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How much help is needed with daily activities (bathing, dressing, eating)?
No assistance needed
Occasional reminders or minimal help
Regular assistance with 1-2 activities
Needs help with most or all daily activities
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How is medication management handled?
Manages all medications independently
Uses pill organizer, mostly independent
Needs reminders or supervision with medications
Requires full medication management by others
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Are there any memory or cognitive concerns?
No memory issues, sharp and alert
Occasional forgetfulness, normal for age
Noticeable memory issues, some confusion
Significant memory loss, diagnosed dementia/Alzheimer's
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How would you describe their social engagement?
Very social, active in community
Some social activities, enjoys company
Becoming more isolated, needs encouragement
Very isolated, withdrawn from activities
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Are there safety concerns at home?
No safety concerns, home is safe
Minor concerns, could use some modifications
Moderate concerns, falls or accidents
Major safety concerns, high risk environment
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