Personal Emergency Response System
Need Evaluation

A personal emergency response system from Life Assist USA medical alert systems gives seniors and those with chronic medical conditions the peace of mind, security, and confidence to continue with daily activities and maintain independence - from their own home. How do you know if you or the person you care for need a medical alarm? Evaluate your need for a medical alert system need by answering the following 9 simple questions.

 Evaluation Form

Your Name:
Email Address:

Question		Yes	No
1) Is it important for the person you care for to continue living independently?
2) As a caregiver, are you having difficulties to find the time you need for yourself?
3) Has this person been hospitalized, or required emergency medical assistance?
4) Has the person fallen frequently, been anxious or at risk of falling where they live?
5) Does this person require an assistive medical device to help with balance or walking?
6) Is this person required to take several medications each day?
7) Do you or your loved suffer from any of the following medical conditions? Hypertension Stroke Congestive Heart Failure Chronic Obstructive Pulmonary Disease Osteoporosis Arthritis Diabetes
8) Does the person you care for require assistance with at least one of the following daily activities? Grooming Bathing Dressing Using the Toilet Eating meals Preparing meals
9) Is the person you care for alone for several hours during the day and/or night?

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The information that you provide to Life Assist USA is stored in a secure location and is never resold. Any information provided to us in this form is only used to provide you more information about your need for a personal emergency response system and medical alert accessories. Thank you for your interest in our medical alert products and services.