Independent Living Assessment

Please tell us who you are thinking of as you complete this assessment: (Typically, this assessment is completed by a person who is responsible for the care or well-being of an aging parent or loved one).

Parent Spouse Other family or friend Don't Know Yourself

What is the gender of the person you are thinking of?

Male Female

How old is the person that you are completing this assessment for?

Under 55 Years 56-64 years 65-70 years 71-75 years 76-80 years 81-85 years 86-90 years Over 90 years Don't Know