| | Yes | No | Sometimes |
| Am I mobile? | | | |
| Do I need help doing things, such as dressing, walking, bathing? | | | |
| Can I still work in my garden? | | | |
| Can I cut the grass or shovel the snow? | | | |
| Can I go shopping for myself? | | | |
| Can I look after my own banking and bill payments? | | | |
| Am I comfortable with living here alone? | | | |
| Do I have problems going up or down the stairs? | | | |
| Do I have independent outings? | | | |
| Am I a prisoner in my own house? | | | |
| Can I clean this house? (Do I want to?) | | | |
| Can I do the laundry? (Do I want to?) | | | |
| Is this house just too big for me? | | | |
| Do I truly enjoy my home? | | | |
| Can I financially carry this house (utilities, taxes etc.)? | | | |
| Does this house require expensive repairs? | | | |
| Is the house in need of modernization? | | | |
| Has the neighborhood changed? | | | |
| Do I have friends or family nearby? | | | |
