Scribd Logo
Upload

Welcome to Scribd!

  • 2K views

    Geriatric Health Questionnaire: Instructions: Please Circle Answers

    Uploaded by

    elvinegunawan
    The document is a geriatric health questionnaire that collects information from elderly patients about their general health, activities of daily living, medical history, living situation, medication management, and memory. It includes questions about vision, hearing, falls, depression, weight loss, incontinence, alcohol use, living arrangements, emergency contacts, medical decision makers, number of medications, medication management system, sexual activity, safety, pneumonia vaccination, and a 3-item memory recall test. The patient is asked to provide information by circling answers, writing short responses, or drawing a clock face setting. A physician reviews and signs the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Geriatric Health Questionnaire: Instructions: Please Circle Answers

    Uploaded by

    elvinegunawan
    2K views2 pages
    The document is a geriatric health questionnaire that collects information from elderly patients about their general health, activities of daily living, medical history, living situation, medication management, and memory. It includes questions about vision, hearing, falls, depression, weight loss, incontinence, alcohol use, living arrangements, emergency contacts, medical decision makers, number of medications, medication management system, sexual activity, safety, pneumonia vaccination, and a 3-item memory recall test. The patient is asked to provide information by circling answers, writing short responses, or drawing a clock face setting. A physician reviews and signs the completed form.

    Original Description:

    scale

    Original Title

    Geriatric Health Questionnaire

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Read this document in other languages

    Did you find this document useful?

    Is this content inappropriate?

    The document is a geriatric health questionnaire that collects information from elderly patients about their general health, activities of daily living, medical history, living situation, medication management, and memory. It includes questions about vision, hearing, falls, depression, weight loss, incontinence, alcohol use, living arrangements, emergency contacts, medical decision makers, number of medications, medication management system, sexual activity, safety, pneumonia vaccination, and a 3-item memory recall test. The patient is asked to provide information by circling answers, writing short responses, or drawing a clock face setting. A physician reviews and signs the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views2 pages

    Geriatric Health Questionnaire: Instructions: Please Circle Answers

    Uploaded by

    elvinegunawan
    The document is a geriatric health questionnaire that collects information from elderly patients about their general health, activities of daily living, medical history, living situation, medication management, and memory. It includes questions about vision, hearing, falls, depression, weight loss, incontinence, alcohol use, living arrangements, emergency contacts, medical decision makers, number of medications, medication management system, sexual activity, safety, pneumonia vaccination, and a 3-item memory recall test. The patient is asked to provide information by circling answers, writing short responses, or drawing a clock face setting. A physician reviews and signs the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    Geriatric Health Questionnaire

    Patients Name: Date:

    Instructions: Please circle answers. 1. General Health: In general, would you say your health is: Excellent / Very Good / Good / Fair / Poor How much bodily pain have you had during the past 4 weeks? None / Very Mild / Mild / Moderate / Severe / Very Severe

    2. Activities of Daily Living: Are you independent (I) (can do by myself), require assistance (A) (need help from another person), or dependent (D) (cannot do at all) with each of the following tasks? Walking Dressing Bathing Eating Toileting Driving I I I I I I A A A A A A D D D D D D Using Telephone Shopping Preparing Meals Housework Taking Medications Managing Finances I I I I I I A A A A A A D D D D D D

    3. Geriatric Review of Systems: a. Do you have difficulty driving, watching TV, or reading because of poor eyesight? .. Yes / No b. Can you hear normal conversational voice? .. Yes / No Do you use hearing aides? ............... Yes / No c. Do you have problems with your memory? . Yes / No d. Do you often feel sad or depressed? . Yes / No e. Have you unintentionally lost weight in the last 6 months? .... Yes / No f. Do you have trouble with control of your bladder? .. Yes / No Do you have trouble with control of your bowels? ...... Yes / No g. How many falls have you had in the past year? h. Do you drink alcohol? . Yes / No If yes, how many drinks per week?
    1

    4. Do you live with anyone? ... Yes / No If yes, who? Spouse / Child / Other / Relative / Friend Who would help you in an emergency? Who would help you with health care decisions if you were not able to communicate your wishes? 5. How many medicines do you take, including prescribed, over the counter, and vitamins? What is your system for taking your medications? Pill box / Family help / List or chart / None 6. Are you sexually active? .. Yes / No 7. Has anyone intentionally tried to harm you? .. Yes / No 8. Have you had a shot to prevent pneumonia? ....... Yes / No 9. Please draw the face of a clock with all the numbers and the hands set to indicate 10 minutes after 11 o'clock.

    Memory: 3 item recall after 1 minute

    (pen, dog, watch)

    # recalled

    Patient Signature: Reviewing Physician:

    Date: Date:

    You might also like