Strong, Capable & Independent Quiz
Personal Information
Full Name
*
First Name
Last Name
E-mail (So we can send you your score.)
*
Click Here to Start Quiz
Strength & Power
I can easily get up from my chair without use of my hands.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I can easily get up from the floor.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I can carry heavy items in from the car when necessary.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I am able to place a stack of heavy dishes in a high cupboard.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
Endurance
I can easily climb 2 flights of stairs
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I have plenty of energy to prepare holiday meals or mow my lawn.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I can walk without tiring for:
*
More than 30 Minutes
30 Minutes
15 Minutes
5 Minutes
Balance
I lose my balance:
*
Rarely
Occasionally
Somewhat Often
Often
In the last 2 years, I have lost my balance without falling on stairs or at curbs:
*
Once
Twice
Three Times
More than Three Times
In the last 2 years, I have fallen:
*
Once
Twice
Three Times
More than Three Times
I can climb the stairs without holding the railing:
*
Always
Usually
Sometimes
Never
Joint Health
After a long day, my knees hurt:
*
Always
Usually
Sometimes
Never
I experience shoulder pain:
*
Always
Usually
Sometimes
Never
My hips ache:
*
Always
Usually
Sometimes
Never
Neuromuscular
My handwriting is clear and crisp.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I could catch a tennis ball thrown from five feet away with one hand.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
When driving, I am easily able to focus on the road and a conversation at the same time.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I find myself bumping into objects in my home:
*
Often
Sometimes
Hardly Ever
Rarely
In the last 6 months, I have tripped and/or slipped without falling:
*
Once
Twice
Three Times
More than Three Times
Cognitive
Compared to in my 30's, I am mentally sharp.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I can keep a short grocery list in my head.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I do mind puzzles (Word games, sudoku, crosswords):
*
Daily
Weekly
Rarely
Never
I am confident in my mental and physical ability to continue to do the activities that I enjoy, and that I must do well into my 90's.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
Submit
Clear Form
Back
Next
Your comments about the quiz
Your Total Score out of 100 Available Points
Your total score out of 100
Back
Next
Thank you for taking our quiz!
If you would like to discuss your results, enter your phone #, pick a time from the calendar below and we will reach out then.
Phone Number (So we can call you at the time you select)
-
Area Code
Phone Number
Appointment
Submit
Should be Empty: