5, 9

Do you live alone?

Do you have a caregiver?

Are you a caregiver?

Consider referral to social worker

Refer to Area Agency on Aging

5, 6

Do you ever feel unsafe where you live?

Has anyone ever threatened or hurt you?

Has anyone been taking your money without your permission?

Social Work assessment

Consider Adult Protective Services Referral

10

Would you like information or forms for a power of attorney for healthcare?

Would you like information on a living will?

Discussion on advance directives

4, 6

Do you need assistance with shopping or finances?

Do you need assistance with bathing or taking a shower?

Instrumental ADL Scale

Basic ADL Scale

4, 6

Do you still drive? If yes:

While driving, have you had an accident in the past 6 months?

Driving concerns by family member?

Vision testing

Consider Occupational Therapy evaluation

1, 3, 4

Do you have trouble seeing, reading, or watching TV? (with glasses, if used)

Vision testing

Consider referral to optometry or opthalmology

1, 3, 4

Do you have difficulty hearing conversations in a quiet room?

Unable to hear whisper test 6-12 inches away?

Cerumen check and removal if impacted

Consider Audiology referral

2, 8

Are you prescribed >5 routine medications?

Do you have difficulty understanding the reason for each of your medications?

Match medications with diagnoses in problem list

Consider reducing doses or discontinuing drugs

2, 3, 6

Have you fallen in the past year?

Are you afraid of falling?

Do you have trouble climbing stairs or rising from chairs?

“Get Up and Go” test

Consider full Fall Assessment

Consider Physical Therapy Evaluation

Consider Home Safety Assessment

2, 3

Do you have any trouble with your bladder?

Do you lose urine or stool when you do not want to?

Do you wear pads or adult diapers?

Consider full Continence Assessment

AUA 7 symptom inventory (men)

2, 3

Weight < 100lbs, or

Unintended weight loss 10 lbs or more over 6 months?

Simplified Nutritional Appetite Questionnaire (SNAQ)

Consider Nutrition evaluation

2, 3

Do you often feel sleepy during the day?

Do you have difficulty falling asleep at night?

Epworth Sleepiness Scale

Consider referral for sleep evaluation

2, 3

Are you experiencing pain or discomfort?

Pain Assessment

3, 5

Do you drink &62; 2 drinks / day?

CAGE Questionnaire

7

Do you often feel sad or depressed?

Have you lost pleasure in doing things over the past few months?

Geriatric Depression Scale

7

Self reported memory loss?

Cognitive screen positive? (3-item recall and Clock Draw test)

Mini Mental State Exam

Consider Neuropsychological testing