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Family
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Martial status
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Children/Grandchildren
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Sexually active
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are you sexually active
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Occupation
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Recent Health
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Health
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History
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Last Mammogram
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Last Colonoscopy
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Last pap smear
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Last Bone Density
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Last Pneumovax/Prevnar
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Last Zoster vaccine
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Last Flu Vaccine
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Last Covid-19 Vaccine
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ADL's
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Do you need help with any of the following
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Hours of sleep per night
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How many hours of sleep a night?
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Vision care (Choose all that apply)
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wears glasses
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Wears reading glasses
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Wears contacts
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Previous LASIX eye surgery
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Having regular Eye exams
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Had an eye exam in the last year?
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No recent eye exam
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Brief Hearing Loss Screener
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Normal hearing
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Slightly Decreased
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Significantly decreased
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Wears hearing aid
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Doesn't wear hearing aid
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3 or more points
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Dental Care (Choose all that apply)
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Good dental hygiene
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brushes how many times per day
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Flosses how many times per day
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Last dental appointment
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Where
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Diet
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Well Balanced
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Unhealthy Diet
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weight concerns
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Concerned about being over weight?
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concerned about being under-Weight
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Interested in weight gain
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Interested in weight loss
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Exercise
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Exercise frequency
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Types of exercise
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Duration
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Dietary supplements
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Supplements choices
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Opioid Use
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Patient acknowledged opioid use. Prescribed by?
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patient acknowledged opioid use and will follow up with PCP
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Patient denies opioid use
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List of all current Providers
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Current providers
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Tobacco Use
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Never been a smoker
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Former cigarette smoker
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Alcohol Use
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Alcohol Use
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How many drinks per day
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how many drinks per week
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How many drinks per month
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Binge Drinking
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Alcohol concers
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Personal concerns
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Family concerned with alcohol use/tolerance
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Annoyance by criticism of alcohol usage
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Attempts to cut out alcohol use
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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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Little interest or pleasure doing things?
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Feeling bad about yourself? Let others down?
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Feeling down, depressed or hopeless
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Trouble concentrating on things. Reading/TV
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Trouble falling/staying asleep, too much
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Moving or speaking so slowly or fidgety
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Feeling tired or having little energy
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Thoughts better off dead or harming yourself
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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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Fall Risk Screen
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I have fallen in the past year
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I use or have been advised to use a cane or walker to get around safely
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Sometimes I feel unsteady when I am walking
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I steady myself by holding onto furniture when I am walking at home
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I am worried about falling
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I need to push with my hands to stand up from a chair
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I have some trouble stepping up onto a curb
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I often have to rush to the toilet
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I have lost some feeling in my feet
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I take medication that sometimes makes me feel light-headed or more tired than usual
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I take medicine to help me sleep or help improve my mood
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I often feel sad or depressed
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Score
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Alcohol Screening
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How often do you have a drink containing Alcohol?
• • •
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How many drinks containing alcohol do you have on a typical day when you are drinking?
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How often do you have 6 or more drinks in one occasion?
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How often during the last year have you found that you were not able to stop drinking once you had started?
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How often during the last year have you failed to do what was normally expected from you because of drinking?
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How often during the last year have you been unable to remember what happened the night before because you had been drinking?
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During the last year have you needed an alcoholic drink the morning to get yourself going after a night of heavy drinking
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How often during the last year have you had a feeling of guilt or remorse after drinking?
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Have you or someone else been injured as a result of your drinking?
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Has a relative, Friend, Doctor, or another health professional expressed concerned about your drinking or suggested you cut
• • •
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