| S2Q1 | Chronic medical condition | Heart failure = 1 Diabetes = 2 Hypertension = 3 HIV = 4 Hepatitis B = 5 Hepatitis C = 6 Osteo arthritis = 7 Parkinson = 8 Alzheimer = 9 CKD = 10 Other (specify) |
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| S2Q2 | Tobacco | No = 1 Yes = 2 If yes Packet - years | /__/__/ |
| S2Q3 | Alcohol consumption | No = 1 Yes = 2 If yes Duration Daily intake |
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| S2Q4 | Previous surgery | No = 1 Yes = 2 (specify) |
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| S2Q5 | Falls | No = 1 Yes = 2 If yes frequency |
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| S2Q6 | Medications/day | 0 = 1, 1 = 2 2 = 3, 3 = 4 4 = 5, >5 = 6 |
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| Frequency 1 = 1, 2 = 2, >3 = 3 |
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