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Mini Cognitive
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Draw numbers on the clock (iPad)
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APPLE, WATCH, PENNY
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Uploaded Clock Image
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Word Recall Score
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Cognitive Score
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Depression Screen - PHQ-9
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1) Little interest or pleasure doing things?
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6) Feeling bad about yourself? Let others down?
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2) Feeling down, depressed or hopeless
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7) Trouble concentrating on things. Reading/TV
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3) Trouble falling/staying asleep, too much
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8) Moving or speaking so slowly or fidgety
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4) Feeling tired or having little energy
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9) Thoughts better off dead or harming yourself
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5) Poor appetite or overeating
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How difficult have these made it for you to....
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Total Score:
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Interpretation Table
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Brief Hearing Loss Screener
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Patient older than 70 (1 point)
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Patient younger than 70
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Gender - Male (1 point)
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Gender - Female
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Highest grade completed 12th or less: 1 point
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Highest grade completed 12th or more: 0 point
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Ever had deafness or trouble hearing?
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If yes to deafness or trouble hearing. See doc?
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w/out aid can understand normal voice across rm
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W/out hearing aid understand whisper across rm?
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3 or more points
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Fall Risk Screen
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Have you had 2 or more falls last 12 months?
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Have you had a fall with injury?
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Do you have any trouble with gait or balance?
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Timed Up and Go
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Score
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Timed Up and Go Test Observation - Safe
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Timed Up and Go Test Observation - Unsafe
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Unsafe Comments
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