Geriatric Assessment – Patient Tool

Your Daily Activities
PATIENT INSTRUCTIONS: Indicate your response by selecting one button per question.

Can you use the telephone…


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Can you get to places out of walking distance…


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Can you go shopping for groceries or clothes (assuming you have transportation)…


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Can you prepare your own meals…


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Can you do your housework…


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Can you take your own medicines…


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Can you handle your own money…


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Does your health limit you in these activities?
The following items are activities you might do during a typical day. Does your health limit you in these activities? (Select an answer that best reflects your situation.)

Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports


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Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf


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Lifting or carrying groceries


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Climbing several flights of stairs


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Climbing one flight of stairs


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Bending, kneeling, or stooping


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Walking more than a mile


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Walking several blocks


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Walking one block


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Bathing or dressing yourself


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Current Health Rating
Which one of the following phrases best describes you at this time?

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Falls
How many times have you fallen in the last 6 months?


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Medications
Are you taking any medications?


How many prescribed medications are you taking?

How many over-the-counter medications are you taking?

How many herbs and vitamins are you taking?

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Your Health
Patient Instructions: Do you have any of the following illnesses at the present time, and if so, how much does it interfere with your activities: Not at All, A Little, or A Great Deal?

Other cancers or leukemia

How much does it interfere with your activities?


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Arthritis or rheumatism

How much does it interfere with your activities?


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Glaucoma

How much does it interfere with your activities?


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Emphysema or chronic bronchitis

How much does it interfere with your activities?


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High blood pressure

How much does it interfere with your activities?


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Heart trouble

How much does it interfere with your activities?


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Circulation trouble in arms or legs

How much does it interfere with your activities?


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Diabetes

How much does it interfere with your activities?


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Stomach or intestinal disorders

How much does it interfere with your activities?


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Osteoporosis

How much does it interfere with your activities?


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Liver disease

How much does it interfere with your activities?


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Kidney disease

How much does it interfere with your activities?


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Stroke

How much does it interfere with your activities?


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Depression

How much does it interfere with your activities?


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How is your eyesight (with glasses or contacts)?




How much does it interfere with your activities?


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How is your hearing (with a hearing aid, if needed)?




How much does it interfere with your activities?


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Do you have any other physical problems or illnesses (other than those listed above) at the present time that seriously affect your health?

If the above answer is yes, please specify the physical problem/illness:
How much does it interfere with your activities?


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Nutritional Status
Have you lost weight involuntarily over the past 6 months?


If yes, how much?


 

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Health Questionnaire
INSTRUCTIONS: These questions are about how you have been feeling within the past month. Please select an answer that best reflects your situation.
How much of the time during the past month:

has your daily life been full of things that were interesting to you?





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did you feel depressed?





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have you felt loved and wanted?





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have you been a very nervous person?





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have you been in firm control of your behavior, thoughts, emotions, feelings?





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have you felt tense or high-strung?





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have you felt calm or peaceful?





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have you felt emotionally stable?





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have you felt downhearted and blue?





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have you felt restless, fidgety, or impatient?





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have you been moody, or brooded about things?





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have you felt cheerful, light-hearted?





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have you been in low or very low spirits?





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were you a happy person?





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did you feel you had nothing to look forward to?





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have you felt so down in the dumps that nothing could cheer you up?





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have you been anxious or worried?





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Social Activities

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?




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Compared to your usual level of social activity, has your social activity during the past 6 months decreased, stayed the same, or increased because of a change in your physical or emotional condition?




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Compared to others your age, are your social activities more or less limited because of your physical health or emotional problems?




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Social Support
INSTRUCTIONS: People sometimes look to others for companionship, assistance or other types of support. How often is each of the following kinds of support available to you if you need it? (Select an answer that best reflects your situation.)

Someone to help if you were confined to bed.




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Someone you can count on to listen to you when you need to talk.




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Someone to give you good advice about a crisis.




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Someone to take you to the doctor if you needed it.




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Someone to give you information to help you understand a situation.




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Someone to confide in or talk to about yourself or your problem.




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Someone to prepare your meals if you were unable to do it yourself.




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Someone whose advice you really want.




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Someone to help you with daily chores if you were sick.




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Someone to share your most private worries and fears with.




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Someone to turn to for suggestions about how to deal with a personal problem.




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Someone who understands your problems.




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Spirituality/Religion
Please answer the following questions about your religious beliefs and/or involvement. Select the answer that best reflects your situation.

How often do you attend church, synagogue, or other religious meetings?





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How often do you spend time in private religious activities, such as prayer, meditation or Bible study?





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The following section contains 3 statements about your religious belief or experience. Please select the extent to which each statement is true or not true for you.

In my life, I experience the presence of the Divine (i.e., God).




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My religious beliefs are what really lie behind my whole approach to life.




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I tried hard to carry my religion over into all other dealings in my life.




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Your Feelings

Do you often feel sad or depressed?

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How would you describe you level of anxiety, on the average? Please select the number (0-10) best reflecting your response to the following that describes your feelings during the past week, including today.










References:
Daily Activities: Older Americans Resources and Services (OARS) IADL: Fillenbaum, G.G., et al., 1981
Physical Activities: Medical Outcomes Study (MOS) Physical Health: Stewart A.L., et al., 1992
Current Health Rating: Karnofsky Self-Reported Performance Rating Scale: Loprinzi, C.L., et al., 1994
Your Health: Older Americans Resources and Services (OARS) Physical Health Section: Fillenbaum, G.G., et al., 1981
Health Questionnaire: MHI-17: Stewart and Ware, 1992
Social Activities: Medical Outcomes Study (MOS) Social Activity Limitations Measure: Sherbourne, C.D., et al., 1991
Social Support: Medical Outcomes Study (MOS) Social Support Survey: Emotional/Informational and Tangible subscales: Sherbourne, C.D., et al., 1991
Spirituality/Religion: DUREL – Duke University Religion Index – Koenig et al., 1997
Your Feelings: Mahoney et al., 1994; LASA – Locke et al., 2007


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