*Denotes required field Do you live alone or are you often home alone?* YesNo Do you shower in your bathtub? YesNo Have you ever slipped or fallen in your bathroom, bedroom or on your stairs? YesNo Are you ever dizzy or light-headed or do you take medication that could make you drowsy? YesNo Do you have mobility issues that make you unsteady on your feet? YesNo Do you have pain or numbness that makes walking difficult? YesNo Are you sometimes worried that you could have a heart attack or stroke when you are alone? YesNo Do you wake up and go to the bathroom in the dark of the middle of the night? YesNo Are you concerned about being trapped in your home by a fire? YesNo Are you concerned you won’t be able to reach your phone to call for help if you need assistance or that you might be too out-of-breath or in too much pain to call? YesNo By submitting your contact information you agree to our Terms of Use and our Security and Privacy Policy. You also expressly consent to having us, our Family of Companies, contact you about your inquiry by text message or phone (including automatic telephone dialing system or an artificial or prerecorded voice) to the residential or cellular telephone number you have provided, even if that telephone number is on a corporate, state, or national Do Not Call Registry. You do not have to agree to receive such calls or messages as a condition of getting any services from Medical Alert or its affiliates.
