checked value="lives alone" /> lives alone checked value="lives with friend" /> lives with friend checked value="lives with child" /> lives with child checked value="lives with spouse" /> lives with spouse checked value="lives with sibling" /> lives with sibling checked value="poor support" /> poor support checked value="socially isolated" /> socially isolated checked value="abusive relationship(s)" /> abusive relationship(s) checked value="relationship problems" /> relationship problems checked value="dependent on Other" /> dependent on Other

checked /> Unsafe stairs and/or doorways checked /> Rugs,cords and/or furniture causing safety risk checked /> Inadequate heating and/or cooling checked /> Unsafe appliances checked /> Inadequate sanitation and/or plumbing checked /> Inadequate refrigeration checked /> Presence of insects and/or rodents checked /> Inadequate smoke detectors checked /> O2 in use without precautions

checked/> unable to meet monthly expenses checked/> excessive spending checked/> can't afford medications checked/> medical needs not met by any insurance including Medicare checked/> unable to manage monthly finances checked/> potential for theft and/or financial abuse

checked/> mobility limitation checked/> speech limitation checked/> hearing limitation checked/> communication limitation checked/> terminal illness