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Tobacco Screening:
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Tobacco Screening
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Total years smoked
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# / day ?
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Date quit smoking
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Drug Misuse Screening:
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Drug Misuse Screening
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If positive, type of drugs?
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Drug misuse screening comments:
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Alcohol Screening:
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Alcohol Screening:
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# drinks/ week
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Type of Alcohol
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Have you consumed 4 or more drinks in one sitting this past year?
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F/u plan?
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Have you ever felt you should cut down on your drinking?
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Have people annoyed you by criticizing your drinking?
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Have you ever felt bad or guilty about your drinking?
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Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
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Depression Screening:
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Little interest or pleasure in doing things
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Feeling down, depressed or hopeless
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Trouble falling or staying asleep, or sleeping too much
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Feeling tired or having little energy
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Poor appetite or overeating
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Feeling bad about yourself- or that you are a failure or have let yourself down
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Trouble concentrating on things, such as reading the newspaper or watching television
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Moving/ speaking slowly or being fidgety/ restless
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SI/ HI
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Total Score:
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Depression Screen: Positive or Negative?
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F/u plan if depression screen positive:
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Fall Risk Screening:
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Have you fallen within the last 12 months?
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If patient has fallen, how many times?
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Is the patient a fall risk?
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Have you suffered a fracture or broken bone due to a fall?
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