1. Choose the appropriate gender:
2. Who are you living with currently?
3. How would you assess your own medical condition?
4. How well can you perform your everyday tasks and activities?
5. Can you travel to places which are out of walking distances?
6. Select the appropriate level of assistance when traveling to distant places:
7. Can you manage your own household work?
8. Choose the degree of help you require when accomplishing household chores:
9. Are there people in your social circle who support you?
10. Choose the level of support you gain from your social gatherings from the following:
11. Do you take care of your physical appearance?
12. Do you prefer visiting a hospital in case of medical emergencies?
13. How would you rate the hospitals in your vicinity to deal with health problems which are connected with old age?
14. If you search for an alternative medical institution for your condition, what would you look for?