Problem - American College of Physicians



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GERIATRIC SCREENING TOOL

Current Height: ____ Height at age 40: ___ Weight: _____

|PROBLEM |SCREENING MEASURE |POSITIVE SCREEN |COMMENTS |

|1. VISION |Ask the question: |“Yes” to question. |( Positive ( Negative |

| |“Because of your eyesight, do you have trouble |Or, inability to read at better |( Ophthalmology Referral |

| |driving a car, watching television, reading or |than 20/40 on the Snellen eye |( ___________________ |

| |doing any of your daily activities?” |chart. |( Performed at another time, see progress note|

| |Or test with the Snellen Eye chart. | |dated ____________ |

|2. HEARING |Ask the patient: |“Yes” to any question. |( Positive ( Negative |

| |“Have you ever been embarrassed about your |Or, inability to repeat correctly |( ENT Referral |

| |hearing? Do you have trouble hearing whispers?|50% of whispered words. |( Audiometry |

| |Do you have trouble hearing at the movies, in |Or, inability to hear 1000 or 2000|( Hearing Aid |

| |theaters, or at religious functions? Does your|Hz in both ears and inability to |( ___________________ |

| |hearing lead to arguments with your family? Do|hear both frequencies in either |( Performed at another time, see progress note|

| |you have trouble hearing particular voices |ear. |dated ____________ |

| |among all the ‘hubbub’ in restaurants?” | | |

| |Or administer the whispered voice test (Mulrow | | |

| |and Lictenstein, JGIM, vol 6, p.250 in the | | |

| |Geriatric Assessment P&P). Or use an audioscope| | |

| |set at 40dB. Test the patient’s hearing using | | |

| |1,000 and 2,000 Hz. | | |

|3. LEG MOBILITY |Time the patient after giving these directions:|Unable to complete task in 15 |( Positive ( Negative |

| | |seconds. |( Fall Prevention Referral |

| |“Rise from the chair. Then walk 10 feet | |( P.T. Consult |

| |briskly, turn, walk back to the chair and sit | |( Assistive Device |

| |down”. | |( ___________________ |

| | | |( Performed at another time, see progress note|

| | | |dated ____________ |

|4. URINARY INCONTINENCE |Ask this question: |“Yes” to this question. |( Positive ( Negative |

| |“In the past year, have you ever lost control | |( Schedule Pelvic Exam |

| |of your urine.” | |( Urodynamic Studies |

| | | |( Urology Referral |

| | | |( ___________________ |

| | | |( Performed at another time, see progress note|

| | | |dated ____________ |

| | | | |

|5. NUTRITION AND WEIGHT |Ask this question: |“Yes” to the question or a weight |( Positive ( Negative |

|LOSS |“ Have you lost 10 lbs. over the past six |loss of > 5%. |( Social Work Referral |

| |months without trying to do so?” | |( Dietary Consult |

| |AND review weights in the chart from the past 6| |( ___________________ |

| |months. | |( Performed at another time, see progress note|

| | | |dated ____________ |

|6. MEMORY |Three item recall. |Unable to remember all three items|( Positive ( Negative |

| |Or, the Folstein’s Mini-Mental Exam`. |after one minute or a score of |( Dementia Work-Up |

| | |less than 25 on the MMSE. |( ___________________ |

| | | |( Performed at another time, see progress note|

| | | |dated ____________ |

|7. DEPRESSION |Ask this question: |“Yes” to the question, and/or |( Positive ( Negative |

| |“Do you often feel sad or depressed?” |meets DSM IV criteria. |( Psych Referral |

| | | |( ___________________ |

| | | |( Performed at another time, see progress note|

| | | |dated ____________ |

|8. ACTIVITIES OF DAILY |Ask the patient these six questions: |If the patient answers no to any |( Positive ( Negative |

|LIVING AND INSTRUMENTAL |“Are you able to go shopping for groceries or |of these questions AND they do not|( Social Work Referral |

|ACTIVITIES OF DAILY LIVING |clothes” |have adequate help. |( ___________________ |

| |“Are you able to bathe—sponge bath, tub bath or| |( Performed at another time, see progress note|

| |shower?” | |dated ____________ |

| |“Are you able to dress yourself: such as put on| | |

| |a shirt; button and zip your clothes; or put on| | |

| |your shoes?” | | |

| |“Are you able to handle your own finances?” | | |

| |“Are you able to make your own meals?” | | |

| |“Are you able to climb the stairs in your | | |

| |home?” | | |

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|9. OTHER | | | |

Performed by: Reviewed by:

___________________________________________________ ________________________________________________

Signature/Date Clinician Signature/Date

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Label or

Name_____________________ DOB_______________________

DOB: ___________________

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