Patient. Name: ________________________________ Date:________________
DOB: ____________________ Spoken Language:_________________________
Who is completing this form: □ myself □ family member □ friend □ other ______________
Rate your overall health: □ excellent □ very good □ good □ fair □ poor
How many times per week do you do the following? (Select the answer)
1. Engage in physical activity (e.g. walking, cycling, etc.) for at least 20 to 30 minutes? □ 0 □ 1 – 2 □ 3 – 4 □ >5
2. Include strength exercises (weights or resistance bands) in your physical activity routine? □ 0 □ 1 – 2 □ 3 – 4 □ >5
3. Eat 5 or more servings of fruits and vegetables (one serving equals
1/2 cup)? □ 0 □ 1 – 2 □ 3 – 4 □ >5
4) Eat 5 or more servings of grains (one serving equals one slice of
bread, 1 cup of cereal, etc.)? □ 0 □ 1 – 2 □ 3 – 4 □ >5
5) Eat 2 or more servings of dairy products (milk, yogurt or cheese)? □ 0 □ 1 – 2 □ 3 – 4 □ >5
6) Eat fast food? □ 0 □ 1 – 2 □ 3 – 4 □ >5
7) Cut the size of your meals or skip meals because you don’t have enough food (not enough money or enough help to shop or cook)? □ 0 □ 1 – 2 □ 3 – 4 □ >5
8) Have more than one drink of alcohol (beer, liquor, wine) per day? □ 0 □ 1 – 2 □ 3 – 4 □ >5
9) Get at least 7 hours of sleep? □ 0 □ 1 – 2 □ 3 – 4 □ >5
10) Use tobacco or nicotine products (cigarettes, e-cigarettes, smokeless tobacco, cigars, or pipes) or are close to others who do? □ 0 □ 1 – 2 □ 3 – 4 □ >5
11) Leave your home to run errands, go to work, go to meetings, classes, church, social functions, etc. (not counting doctor’s visits)? □ 0 □ 1 – 2 □ 3 – 4 □ >5
12) Have physical pain that affects your activities? □ 0 □ 1 – 2 □ 3 – 4 □ >5
13) Do you visit your dentist for regular check-ups at least every six months if you have natural teeth, or once a year if you have full dentures? □ Yes □ No
14) Do you have enough money to pay for the medications, medical supplies, and medical visits that you need? □ Yes □ No
15) About how many times in the last month have you missed taking your medications? _______ times □ I don’t take medicines
16) About how many times in the last month have you taken your medication differently than prescribed by your doctor? (skip if you don’t take medicines) _______ times
17) Do you take any over-the-counter medications (vitamins, supplements, herbal medicines)? □ Yes □ No
18) Do you have sufficient transportation to make all of your medical appointments? □ Yes □ No
19) In the past 12 months, have you had any problem with balance or walking, or have you had any falls? If Yes to falls, how many times?_____ □ Yes □ No
20) In the past 6 months, have you had a problem with leakage of urine? □ Yes □ No
21) In the past month, have you needed help managing your finances? □ Yes □ No
22) Do you think anybody is taking or using your money without your permission? □ Yes □ No
23) In the past 7 days, have you needed help from others:
24) To eat, bathe, get dressed or use the toilet? □ Yes □ No
25) To do laundry, cooking, housekeeping or shopping? □ Yes □ No
26) For transportation? □ Yes □ No
27) To take your medications? □ Yes □ No
28) Do you or your caregiver have sufficient help/support with and resources for caregiving duties? (skip if you do not give or receive care) □ Yes □ No
29) Are you satisfied with your current level of social interaction with family and friends, and participation in activities outside your home? □ Yes □ No
30) Do you have family and friends who care about you and you can count on for help when you need something or have a problem? □ Yes □ No
31) Is anybody mistreating you? □ Yes □ No
32) Do you have an Advance Directive or Living Will? □ Yes □ No
Over the last two weeks, how often have you been bothered by the following problems? □ not at all □ several days □ > half of the days □ nearly every day
33) Little interest or pleasure in doing things? □ not at all □ several days □ > half of the days □ nearly every day
34) Feeling down, depressed or hopeless? □ not at all □ several days □ > half of the days □ nearly every day
35) Having anxiety or stress about your health, finances, family, work or social relationships? □ not at all □ several days □ > half of the days □ nearly every day
For Provider Use Only
Height: ______ Weight: _______ BMI: _______ BP: ____/____ P:______
PHQ -2 Score: ____ PHQ-9 Score (if indicated):________
Other mental health screen, if indicated: (name/score) ______
Mini-Cog Score: _______ Other cognitive screen, if indicated: (name/score) ____________
Timed Up and Go: ___________________________________________________
□ Home safety checklist reviewed
□ Personal Preventive Plan completed and reviewed with patient
Information/education provided:
□ Exercise □ Healthy Eating □ Dietary supplements □ Food Banks/Meals on Wheels
□ Fall prevention □ Pain □ Depression □ Sleep
□ Cognitive impairment □ Medication use □ Transportation resources
□ Caregiver resources □ Abuse prevention □ Scam prevention
□ Veteran’s benefits □ Health Insurance Counseling Advocacy Program(HICAP)
□ Speech/hearing center □ Braille Institute □ Advance Directive/Living Will
□ Adult Day Care □ Alzheimer’s Association □ Long Term Support Services (LTSS)
□ Other __________________________________________
Referrals made/provided:
□ Dental □ Optometry □ PT evaluation □ Pain management □ Dementia evaluation
□ Psychiatry/Counseling/behavioral health □ Dietician/nutrition counseling
□ Bone Mineral Density □ Colonoscopy □ Mammogram □ Pap smear
□ Alcohol reduction □ Tobacco cessation □ Chronic Disease Self-Management Class
□ Case management □ Driving evaluation □ Friendly visitor program
□ Other ___________________________________________________