CESAM : Evaluate your health status

* Your Gender:

• Male
• Female
• Neutral

* Your Birth Date:

* Have you involuntarily lost weight in the past year?

• Yes
• No

* If yes, was the lost of weight above 3kg / 6lbs?

• Yes
• No

* How many different drugs do you take daily?

• None
• 1 to 4
• 5 to 9
• 10 or more

* Do you have vision problems?

• Yes
• No

* Do you have hearing problems?

• Yes
• No

* Has someone around you noticed that you have memory problems?

• Yes
• No

* Do you receive home-help services?

• Yes
• No

* If yes, who helps you?

• Family
• and/or Friends
• and/or Professional

* Do you need help for grooming?

• Yes
• No

* Do you need help for bathing?

• Yes
• No

* Do you need help to get dressed?

• Yes
• No

* Do you need help for walking and/or other displacements?

• Yes
• No

* Do you need help for eating?

• Yes
• No

* Do you need help to use the phone?

• Yes
• No

* Do you need help to take public transports?

• Yes
• No

* Do you need help to manage your medications?

• Yes
• No

* Do you need help to handle your own finances?

• Yes
• No

* Are you incontinent (urine and/or stool)?

• Yes
• No

* How do you feel today?

• Happy
• Unhappy
• Neither one nor the other

* Do you feel energetic?

• Yes
• No

* Did you do regular physical activities (walking, bicycle, etc…), at least one hour per week in the past month?

• Yes
• No

* Did you fall in the previous year (at least one fall)?

• Yes
• No

* Have you received help to complete this questionnaire?

• Yes
• No

* If yes, who helped you?

• Family
• Friend
• Professional

* Which family member helped you?

• Spouse / Partner
• Child
• Other

* How did you find out about this questionnaire?

• Doctor: Family doctor, medical specialist, emergency room physician
• Health and/or social professional
• Other

* Did you answer this questionnaire for yourself or for someone else?

• Myself
• Someone else

* Are you the caregiver to an individual who is suffering from a chronic illness?

• No
• Yes

* What is his/her condition?

• Alzheimer's disease
• Other

* Do you want to register on the CESAM evaluation platform?

• Yes, sign me up!
• No