| Self-care (physical or cognitive function) |
- IADLs*
- Are you able to pay your own bills, or do you need help with your checkbook?
- Do you do your own cooking?
- How do you get to your doctor appointments? - Do you sometimes find yourself confused? (Mini-Cog¶[1])
- Can you climb a flight of stairs? If not, what limits you? (eg, pain, dyspnea, strength, balance)
- Do you require assistance with bathing? (ADLsΔ)
- When was the last time you fell? What happened?
- Do you have difficulty with balance or walking?
|
| Advance directives |
- Do you have an advance directive?
- Who would you like to help you make medical decisions, or make them in your place in the event you are unable to participate in the discussion?
- Rank the following (in order of preference) of how you would like us to focus your care[2]:
1) Life prolongation
2) Maintaining function
3) Comfort |
| Living situation and social support |
- Who do you turn to when you need help?
- Who do you live with?
- What kind of help do you have at home?
- Where you live, do you have:
- Meals prepared for you
- Help taking your pills, checking your blood sugar, etc
- Do you need to climb stairs to get to your apartment/home/bedroom? |
| General screening |
| Nutrition | Have you lost any weight in the last year?[3] |
| Visual impairment | Do you have difficulty driving, watching TV, or reading because of your eyesight? |
| Hearing | Do you have difficulty hearing or understanding what a person says talking in a normal voice? |
| Urinary incontinence | Do you sometimes lose control of your urine and, if so, is that bothersome to you? |
