Please describe your current health issues:
How do these issues impact your daily life?
During the past six months, how many times have you seen a doctor?
During the past six months, how many days were you so sick that you were unable to carry on your usual activities?None A Week or Less More Then a Week
During the past six months, were you in a hospital for health issues?Yes No
If yes, how many days were you hospitalized?
What sort of health issues were you hospitalized for?
How would you rate your overall health at the present time?Excellent Good Fair Poor
How would you rate your overall health compared to a year ago?Better About the same Worse
How much do your health issues stand in the way of your doing the things you want to do?Not at all A little A great deal
Do you have periods of confusion or forgetfulness that interfere with your daily activities?Yes No
Please select all that apply to your mental status:Confused Forgetful Difficulty expressing self Wandering Sociable Withdrawn Depression Anxiety
Please list your medications including dosages, frequency, and time of day. Please include supplements and over the counter medications as well: What other medications (short-term) have you taken in the past month?
Do you need assistance taking medications?Yes No
If yes, please describe:
Are you allergic to any medication or food?Yes No
If yes, please describe any reactions you have experienced:
Do you have any dietary restrictions?Yes No
If yes, please describe
Do you have any difficulty eating or drinking?Yes No
If yes, please describe
Do you use any of the following aids?Wheelchair Cane Walker Glasses Contact Lenses Dentures Hearing Aid
Other:
How is your eyesight?Excellent Good Fair Poor Totally Blind
Other:
Have you ever had a drinking problem or has your doctor ever advised you to cut down on drinking?Yes No
Do you use tobacco/nicotine products including chewing tobacco?Yes No
Do you use marijuana?Yes No
Do you feel that you need medical care or treatment beyond what you are receiving at this time?Yes No
If yes, please describe
How well do you walk?Alone Alone with a cane, walker, etc Only with the help of another person Cannot Walk
Do you have difficulty keeping your balance while walking?Yes No
Is your sleep disturbed?Yes No
How many hours a night do you usually sleep?
Are you troubled by your heart pounding or by shortness of breath?Yes No
Taking everything into consideration, how would you describe your satisfaction with life in general at the present moment?Excellent Good Fair Poor
How would you rate your mental or emotional health at the present time?Excellent Good Fair Poor
Compared to one year ago, how would you rate your mental or emotional health?Better About the same Worse
How well do you use the telephone?Without help With some help Unable to use telephone
Do you cook meals for yourself?Without help With some help Unable to cook meals
Do you handle your own money?Without Help (write checks, pay bills, etc) With some help (manage day to day budgeting, but need help managin checkbook and paying bills) I do not handle my own money
Are you able to feed yourself?Without help (able to feed yourself completely) With some help (need some cutting meat, etc) I am not able to feed myself
Do you dress and undress yourself?Without help (able to select clothes, dress, and undress) With some help I am not able to dress myself
Do you take care of your own appearance? For example: combing your hair or shavingWithout help With some help I am unable to take care of my appearance
How do you get in and out of bed?Without any help or aids With some help (either from a person or with the aid of a device)
Explain:
How do you bathe?Without help With some help (getting in and out of tub or shower or need special attachments)
Explain:
Do you ever have trouble getting to the bathroom on time?Yes No
How often do you wet or soil yourself?Once or twice a week Three times a week Never
Have there been any recent changes in care needs?Yes No
If yes, please explain:
During the past six months, have you had any help with things suck as shopping, cooking, taking medications, housework, bathing, dressing, and getting around?Yes No
If yes, who is your major helper?
Are you receiving any assistance from an outside agency, such as Home Health?Yes No
If yes, please describe:
Is religion important in your life?Yes No
Do you have any religious beliefs potentially impacting your care?Yes No
If yes, How often do you attend services and where?
Is there anything else you would like us to know about your physical, mental, emotional, or spiritual health?
