1. Please imagine that this pre-drawn circle is a clock. I would like you to place the numbers in the correct positions then place the hands to indicate a time of ‘ten after eleven’

2. In the past year, how many times have you been admitted to a hospital?

3. In general, how would you describe your health?

4. With how many of the following activities do you require help? (meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications)

5. When you need help, can you count on someone who is willing and able to meet your needs?

6. Do you use five or more different prescription medications on a regular basis?

7. At times, do you forget to take your prescription medications?

8. Have you recently lost weight such that your clothing has become looser?

9. Do you often feel sad or depressed?

10. Do you have a problem with losing control of urine when you don’t want to?

11. I would like you to sit in this chair with your back and arms resting. Then, when I say ‘GO’, please stand up and walk at a safe and comfortable pace to the mark on the floor (approximately 3 m away), return to the chair and sit down’