Answer all 15 items
1. Can you do shopping independently?
2. Can you walk around outside independently?
3. Can you dress and undress yourself independently?
4. Can you go to the toilet independently?
5. What mark do you give your physical fitness (1-10)?
6. Do you experience problems in daily life due to poor vision?
7. Do you experience problems in daily life due to poor hearing?
8. Have you lost a lot of weight unintentionally during the last 6 months?
9. Do you take 4 or more different types of medicine?
10. Do you have complaints about your memory?
11. Do you sometimes experience an emptiness around you?
12. Do you sometimes miss people around you?
13. Do you sometimes feel abandoned?
14. Did you recently feel sad or dejected?
15. Did you recently feel nervous or anxious?
Verified
Last Review: 2026
Last Comprehensive Review: 2026
