Health/Medical

Concerns/Changes Noted

Scale 1-10

Health, pain or discomfort complaints?

Has not been to doctor in past 6 months?

Existing health diagnoses?

Any new diagnosis or recent hospitalization?

Doctor request for changes to his/her habits, lifestyle, or diet?

Taking medications for which diagnoses or conditions?

Number of medications taking? Taking medications as prescribed?

Other:

Memory

Concerns/Changes Noted

Scale 1-10

Concerns about parent leaving on the stove, oven, or iron?

Parent repeats him/herself? Asks same question twice in conversation?

Wandering from home and having difficulty getting back?

Missing appointments?

Other:

Physical appearance

Concerns/Changes Noted

Scale 1-10

Signs of fall or other injury?

Changes in hygiene?

Shortness of breath?

Swollen feet or ankles?

Other:

Functional

Concerns/Changes Noted

Scale 1-10

History of falls?

Difficulty using bathroom, shower or toilet?

Uses cane, walker or wheel chair?

Difficulty of speech, hearing or vision?

Concerns expressed by neighbors, friends?

In-home risk factors (rugs, etc)?

Recent traffic accidents or failure to heed traffic signals?

Worried about him/her driving?

Other:

Mood/behavior

Concerns/Changes Noted

Scale 1-10

Loss of interest in previous activities?

Talks about feeling hopeless?

Socially isolated?

Mood swings or getting angry quickly?

Other:

Diet

Concerns/Changes Noted

Scale 1-10

Lack of food in the home?

Eats alone and not motivated to prepare meals?

Increased or excessive consumption of alcohol or medications?

Adhering to prescribed diet?

Noticeable weight gain or loss?

Other:

COMMENTS: