Cognition |
Pre-drawn circle. Add the numbers in the correct positions to make a clock then place the hands to indicate a time of 10 after 11 |
No errors |
Minor errors |
Major errors |
General health |
In the past year, how many times have you been admitted to a hospital? In general, how would you describe your health? |
0 Good/Excellent |
1–2 Fair |
>2 Poor |
Functional independence |
With how many of the following activities do you require help? - Meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications
|
0–1 |
2–4 |
>4 |
Social support |
When you need help, can you count on someone who is willing and able to meet your needs? |
Always |
Sometimes |
Never |
Medication use |
Are you on five or more different prescription medications on a regular basis? At times, do you forget to take your prescription medications? |
No No |
Yes Yes |
|
Nutrition |
Have you recently lost weight |
No |
Yes |
|
Mood |
Do you often feel sad or depressed? |
No |
Yes |
|
Continence |
Have you experienced incontinence |
No |
Yes |
|
Functional performance |
Two weeks ago, were you able to: • Do heavy work around the house like washing windows, walls, or floors without help? • Walk up and down stairs to the second floor without help? • Walk 1 km without help? |
Yes Yes Yes |
No No No |
|