Yes

No

Question

Does your loved one know how to use the telephone in case of an emergency?

Is your loved one able to state the phone number for #911 when prompted?

Is your loved one able to recognize a dangerous situation, for example, fire?

Does your loved one become confused or unpredictable under stress?

Does your loved one show signs of depression, frustration, or withdrawal when left home alone?

Does your loved one attempt to perform tasks independently despite safety concerns that might now warrant supervision (such as cooking, laundry, ironing, bathing, shopping)?

Have recent difficulty operating appliances, temperature or remote controls, doors/windows?

Does your loved one have difficulty reading and/or understanding directions, warning labels, clock/watch, letters/bills, TV guide, etc.?

Does your loved one make slow or poor decisions when performing tasks within the home?

Does your loved one wander and become disoriented?