| Cognition |
- Please imagine that this pre-drawn circle is a clock.
- Please place the numbers in the correct positions and
- Then place the hands to indicate a time of “ten past eleven”
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- 0 – no errors
- 1- minor spacing errors
- 2- other errors
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| General Health Status |
In the past year how many times have you been admitted to the hospital? |
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In general, how would you describe your health? |
- 0-excellent, very good , or good
- 1-fair,
- 2-poor
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| Functional Independence |
With how many of the following activities do you help: meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications? |
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| Social Support |
When you need help, can you count on someone who is willing and able to meet your needs? |
- 0-always,
- 1-sometimes,
- 2-never
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| Medication Use |
Do you use five or more prescriptions on a regular basis? |
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At times do you forget to take your prescription medications? |
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| Nutrition |
Have you recently lost weight so that your clothing has become looser? |
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| Mood |
Do you often feel sad or depressed? |
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| Continence |
Do you have a problem with losing control of urine when you don’t want to? |
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| Functional |
Please sit in this chair with your back and arms resting. When I say “go”, please stand up and walk to the mark on the floor (approximately 10 feet away), then turn around, return to the chair and sit down. |
- 0-10 seconds or less
- 1-11 to 20 seconds
- 2->20 seconds or unwilling, unable
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