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Lifeline: Medical Alert Form

Lifeline: Medical Alert Form

A medical alert service gives older adults and those with chronic medical conditions the security and confidence to continue to live independently at the one place they feel most comfortable – their own home.To find out if it’s time to consider a medical alert for yourself or someone you care for, please answer the questions below. The total of “YES” responses indicates the level of need for a medical alert system.

When you’re done, tally up the number of “YES” responses..

Your total points indicate the level of need for a medical alert as follows:

6 – 9 Points – IMMEDIATELY Recommended

3- 5 Points – Highly Recommended

0 – 2 Points – Limited Need A medical alert system is an option should the situation change.

* Indicates required information
Date *    (mm/dd/yyyy)
1. Are you alone for several hours during
the day or night? * 

2. In the past year, have you fallen, been
anxious about falling, or otherwise been
at risk of falling in your home? * 

3. Have you been hospitalized or to the
emergency room in the past year? * 

4. Do you have one of these chronic
ailments: heart disease, stroke, COPD,
osteoporosis, diabetes, arthritis? * 

5. Do you use a cane, walker, wheelchair,
stair climber, or other assitive device to
help with balance or walking? * 

6. Are you required to take several
daily medications? * 

7. Do you require assistance with one or more
of the following: bathing, toileting, dressing,
meal prep, taking medications? * 

8. Would a medical alert service provide
peace of mind for your loved ones? * 

9. Is is important to you to continue
living independently? * 

Total POINTS 
Name * 
Email Address 
Street Address 2 
Street Address 1 * 
City * 
State * 
Zip * 
Phone * 
Would you like someone to contact you? 
 

Page last updated on Sep. 24, 2010