Comprehensive Older Person Evaluation and Home Safety Checklist

Name (print): __Jacob____________________________________________________________________ Date of Visit:

_________________________

Chief complaint:

_______Hypertension_____________________________________________________________________________________________________

Today I will ask you about your overall health and function and will be using a questionnaire to help me obtain this information. The first few questions are to check your memory.

Preliminary Cognition Questionnaire: Record if answer is correct with ( ); if answer is incorrect, with ( ). Record total number of errors.

( , )

1) What is the date today? ______

2) What day of the week is it? ______

3) What is the name of this place? ______

4) What is your telephone number or room number? (record answer: _______) ______

If subject does not have phone, ask:

What is your street address?

5) How old are you? (record answer: _______) ______

6) When were you born? (record answer from records if patient cannot answer: _______) ______

7) Who is the president of the United States now? ______

8) Who was the president just before him? ______

9) What was your mother’s maiden name? ______

10) Subtract 3 from 20 and keep subtracting from each new number you get, all the way down. ______

Total errors ______

If more than 4 errors, ask #11. If more than 6 errors, complete questionnaire from informant.

11) Do you think you would benefit from a legal guardian, someone who would be responsible for your legal and financial matters?

Do you have a living will? Would you like one?

a) No

b) Has functioning legal guardian for sole purpose of managing money

(describe: ______________________________________________________________________)

c) Has legal guardian

d) Yes

Demographic Section

1) Patient’s race or ethnic background (record: _______________)

2) Patient’s gender (circle) Male Female

3) How far did you go in school?

a) Postgraduate education

b) Four-year degree

c) College or technical school

d) High school complete

e) High school incomplete

f) 0-8 years

Social Support Section: Now there are a few questions about your family and friends.

4) Are you married, widowed, separated, divorced, or have you never been married?

a) Now married

b) Widowed

c) Separated

d) Divorced

e) Never married

5) Who lives with you? (circle all responses)

a) Spouse

b) Other relative or friend (specify: _______________________)

c) Group living situation (non-health)

d) Lives alone

e) Nursing home, number of years

6) Have you talked to any friends or relatives by phone during the last week?

a) Yes

b) No

7) Are you satisfied by seeing your relatives and friends as often as you want to, or are you somewhat dissatisfied about how little you see them?

a) Satisfied (skip to #8)

b) No (ask A)

A) Do you feel you would like to be involved in a Senior Citizens Center for social events, or perhaps meals?

1) No

2) Is involved (describe: _________________________)

3) Yes

8) Is there someone who would take care of you for as long as you needed if you were sick or disabled?

a) Yes (skip to C)

b) No (ask A)

A) Is there someone who would take care of you for a short time?

1) Yes (skip to C)

2) No (ask B)

B) Is there someone who could help you now and then?

1) Yes (ask C)

2) No (ask C)

C) Whom would we call in case of an emergency? (record name and telephone: ______________________

________________________________________________)

Financial Section

9) Do you own, or are you buying, your own home?

a) Yes (skip to #10)

b) No (ask A)

A) Do you feel you need assistance with housing?

1) No

2) Has subsidized or other housing assistance

3) Yes (describe: ________________________________)

B) What type of housing did you have prior to coming here?

10) Are you covered by private medical insurance, Medicare, Medicaid, or some disability plan? (circle all that apply)

a) Private insurance (specify and skip to #11): )

b) Medicare

c) Medicaid

d) Disability (specify and ask A: _________________________)

e) None

f) Other (specify: ______________________________________)

A) Do you feel you need additional assistance with your medical bills?

1) No

2) Yes

11) Which of these statements best describes your financial situation?

a) My bills are no problem to me (skip to #12)

b) My expenses make it difficult to meet my bills (ask A)

c) My expenses are so heavy that I cannot meet my bills (ask A)

A) Do you feel that you need financial assistance such as: (circle all that apply)

1) Food stamps

2) Social Security or disability payments

3) Assistance in paying your heating or electrical bills

4) Other financial assistance (describe: ____________)

Psychological Health Section: The next few questions are about how you feel about your life in general. There are no right or wrong answers, only what best applies to you. Please answer yes or no to each question.

Yes No

_____ _____

12) Is your daily life full of things that keep you interested?

_____ _____ 13) Have you, at times, very much wanted to leave home?

14) Does it seem that no one understands you? _____ _____

15) Are you happy most of the time? _____ _____

16) Do you feel weak all over much of the time? _____ _____

17) Is your sleep fitful and disturbed? _____ _____

18) Taking everything into consideration, how would you describe your satisfaction with your life in general at the present time—good, fair, or poor?

a) Good

b) Fair

c) Poor

19) Do you feel you now need help with your mental health; for example, a counselor or psychiatrist?

a) No

b) Has (specify: _______________________________________)

c) Yes

Physical Health Section: The next few questions are about your health.

20) During the past month (30 days), how many days were you so sick that you couldn’t do your usual activities, such as working around the house or visiting with friends?

21) Relative to other people your age, how would you rate your overall health at the present time: excellent, good, fair, poor, or very poor?

a) Excellent (skip to #22)

b) Very good (skip to #22)

c) Good (ask A)

d) Fair (ask A)

e) Poor (ask A)

A) Do you feel you need additional medical services such as a doctor, nurse, visiting nurse, or physical therapist? (circle all that apply)

1) Doctor

2) Nurse

3) Visiting nurse

4) Physical therapist

5) None

22) Do you use an aid for walking, such as a wheelchair, walker, cane, or anything else? (circle aid usually used)

a) Wheelchair

b) Other (specify: ______________________________________)

c) Visiting nurse

d) Walker

e) None

23) How much do your health troubles stand in the way of your doing things you want to do: not at all, a little, or a great deal?

a) Not at all (skip to #24)

b) A little (ask A)

c) A great deal (ask A)

A) Do you think you need assistance to do your daily activities; for example, do you need a live-in aide or choreworker?

1) Live-in aide

2) Choreworker

3) Has aide, choreworker, or other assistance (describe: ____________________________________)

4) None needed

24) Have you had, or do you currently have, any of the following health problems? If yes, place an “X” in appropriate box and describe; medical record information may be used to help complete this section.

HX

CURRENT

DESCRIBE

a) Arthritis or rheumatism?

b) Lung or breathing problem?

c) Hypertension?

d) Heart trouble?

e) Phlebitis or poor circulation problems in arms or legs?

f) Diabetes or low blood sugar?

g) Digestive ulcers?

h) Other digestive problem?

i) Cancer?

j) Anemia?

k) Effects of stroke?

l) Other neurological problem?(specify: ___________)

m) Thyroid or other glandular problem? (specify:

___________)

n) Skin disorders such as pressure sores, leg ulcers, burns?

o) Speech problem?

p) Hearing problem?

q) Vision or eye problem?

r) Kidney or bladder problems, or incontinence?

s) A problem of falls?

t) Problem with eating or your weight? (specify:

___________)

u) Problem with depression or your nerves? (specify:

___________)

v) Problem with your behavior (specify: ______

____________________)

w) Problem with your sexual activity?

x) Problem with alcohol?

y) Problem with pain?

z) Other health problems?(specify: ___________)

Immunizations: _____________________________________________

_________________________________________________________

25) What medications are you currently taking, or have been taking, in the last month? (May I see your medication bottles?) (If patient cannot list, ask categories a-r and note dosage and schedule, or obtain information from medical or pharmacy records and verify accuracy with the patient.)

Allergies:

Rx (DOSAGE AND SCHEDULE)

a) Arthritis medication

b) Pain medication

c) Blood pressure medication

d) Water pills or pills for fluid

e) Medication for your heart

f) Medication for your lungs

g) Blood thinners

h) Medication for your circulation

i) Insulin or diabetes medication

j) Seizure medication

k) Thyroid pills

l) Steroids

m) Hormones

n) Antibiotics

o) Medicine for nerves or depression

p) Prescription sleeping pills

q) Other prescription drugs

r) Other nonprescription drugs

26) Many people have problems remembering to take their medications, especially ones they need to take on a regular basis. How often do you forget to take your medications? Would you say you forget often, sometimes, rarely, or never?

a) Never c) Sometimes

b) Rarely d) Often

Activities of Daily Living: The next set of questions asks whether you need help with any of the following activities of daily living.

27) I would like to know whether you can do these activities without any help at all, or if you need assistance to do them. Do you need help to: (If yes, describe, including patient needs.)

YES

NO

DESCRIBE (INCLUDE

NEEDS)

a) Use the telephone?

b) Get to places out of walking distance (using transportation)?

c) Shop for clothes and food?

d) Do your housework?

e) Handle your money?

f) Feed yourself?

g) Dress and undress yourself?

h) Take care of your appearance?

i) Get in and out of bed?

j) Take a bath or shower?

k) Prepare your meals?

l) Do you have any problem getting to the bathroom on time?

28) During the past 6 months, have you had any help with such things as shopping, housework, bathing, dressing, and getting around?

a) Yes (specify: ________________________________________) b) No

Signature of person completing the form: