Senior Citizen Health Risk Questionnaire

Personal Information

Full Name Date of Birth Gender Male Female Other

Medical History

Do you currently have or have you ever been diagnosed with any of the following?

Diabetes Hypertension Heart Disease Stroke Cancer Asthma Arthritis None

Other medical conditions (please specify)

Lifestyle

Do you smoke?

Yes No Former Smoker

Do you consume alcohol?

Yes No Occasionally

How many days per week do you exercise?

Functional Assessment

Do you require assistance with any of the following activities?

Bathing Dressing Eating Toileting Mobility None

Additional Comments

Please provide any other relevant information