Senior Life Solutions Program Form - Van Buren County Hospital

Have you lost interest in activities you previously enjoyed?

Yes
No

Have you recently lost a loved one?

Yes
No

Have you experienced feelings of sadness or grief lasting longer than two weeks?

Yes
No

Have you experienced a loss of energy or feeling tired all the time?

Yes
No

Do you have a chronic health condition?

Yes
No

Have you had a recent health diagnosis?

Yes
No

Have you experienced changes in appetite? (eating too much or too little)

Yes
No

Have you experienced a change in sleeping patterns? (sleeping too much or too little)

Yes
No

Have you had trouble concentrating or thinking clearly?

Yes
No

Do you feel hopeless, like you've lost control of your life?

Yes
No

Do you feel isolated or lonely?

Yes
No

Are you the primary caregiver for a friend or loved one?

Yes
No

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Senior Life Solutions Form