TABLE 1.

Outpatient survey form.

Basic information
Name
Age
Address
Insurance and Service Availability
Health insurance
Disability certificate
Care level certificate	Requiring help level: 1, 2 Long‐term care level: 1, 2, 3, 4, 5
Home‐care service provider
Care manager
Service	Home‐visit nursing: Nursing station (  ) Frequency (  )[/week]
	Home help: Care station (  ) Frequency (  )[/week]
	Home‐visit rehabilitation: Rehab station (  ) Frequency (  )[/week]
	Short‐term stay at care facilities
	Other
Contact
Emergent contact (First)	Name: Relationship: Phone number: Address:
Emergent contact (Second)	Name: Relationship: Phone number: Address:
Activity of Daily Living (ADL)
Mobility (Ambulation)	Independent, Under observation, With cane, With rollator, On wheelchair, Totally dependent
Bathing	Independent, Partially dependent, Totally dependent
	Place: Home, Day‐time care, Day‐time rehabilitation, Home‐visit bathing care, Other
Toileting	Independent, With help, Bedside commode, Diaper
Falling within 6 months	Yes, No
Instrumental ADL
Meal preparation
Finance management
Housekeeping
Telephone use
Laundry
Medication management	Self, Family member (  ), Other (  )
Shopping
Access to clinic	On foot, Bus, taxi, Transportation by family, Other
Cognitive function
Communication	Anything (e.g., hearing loss, articulation disorder)
Family member
Pedigree
Primary caregiver
Reliable person other than family member (e.g., friends, neighbors)
Backgrounds
Housing	Own, Rent, Public, Nursing facility
	Elevator: Yes, No
	Front stoop: Yes, No
	Steps: Yes, No
	Handrail: Yes, No
Finance	Working, Pension, Welfare, Other
Life history
Community participation
Community for health promotion
Patient hope and planning
Assessment
Next step (e.g., service introduction, conference, and information sharing)