ࡱ> IKH zbjbj 4>ee6Zff$$$8\p$nUUU_aaaaaa$NU3"UUU?///U8_/U_//:,#0dZw,} K0 e##(UU/UUUUU/UUUUUUUUUUUUUUUUf :   GERIATRIC SCREENING TOOL Current Height: ____ Height at age 40: ___ Weight: _____ PROBLEMSCREENING MEASUREPOSITIVE SCREENCOMMENTS1. VISIONAsk the question: Because of your eyesight, do you have trouble driving a car, watching television, reading or doing any of your daily activities? Or test with the Snellen Eye chart.Yes to question. Or, inability to read at better than 20/40 on the Snellen eye chart.( Positive ( Negative ( Ophthalmology Referral ( ___________________ ( Performed at another time, see progress note dated ____________2. HEARINGAsk the patient: Have you ever been embarrassed about your hearing? Do you have trouble hearing whispers? Do you have trouble hearing at the movies, in theaters, or at religious functions? Does your hearing lead to arguments with your family? Do you have trouble hearing particular voices 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 patients hearing using 1,000 and 2,000 Hz. Yes to any question. Or, inability to repeat correctly 50% of whispered words. Or, inability to hear 1000 or 2000 Hz in both ears and inability to hear both frequencies in either ear.( Positive ( Negative ( ENT Referral ( Audiometry ( Hearing Aid ( ___________________ ( Performed at another time, see progress note dated ____________3. LEG MOBILITYTime the patient after giving these directions: Rise from the chair. Then walk 10 feet briskly, turn, walk back to the chair and sit down. Unable to complete task in 15 seconds.( Positive ( Negative ( Fall Prevention Referral ( P.T. Consult ( Assistive Device ( ___________________ ( Performed at another time, see progress note dated ____________ 4. URINARY INCONTINENCEAsk this question: In the past year, have you ever lost control of your urine. Yes to this question.( Positive ( Negative ( Schedule Pelvic Exam ( Urodynamic Studies ( Urology Referral ( ___________________ ( Performed at another time, see progress note dated ____________ 5. NUTRITION AND WEIGHT LOSSAsk this question: Have you lost 10 lbs. over the past six months without trying to do so? AND review weights in the chart from the past 6 months. Yes to the question or a weight loss of > 5%.( Positive ( Negative ( Social Work Referral ( Dietary Consult ( ___________________ ( Performed at another time, see progress note dated ____________6. MEMORYThree item recall. Or, the Folsteins Mini-Mental Exam`. Unable to remember all three items after one minute or a score of less than 25 on the MMSE. ( Positive ( Negative ( Dementia Work-Up ( ___________________ ( Performed at another time, see progress note dated ____________7. DEPRESSIONAsk this question: Do you often feel sad or depressed? Yes to the question, and/or meets DSM IV criteria.( Positive ( Negative ( Psych Referral ( ___________________ ( Performed at another time, see progress note dated ____________8. ACTIVITIES OF DAILY LIVING AND INSTRUMENTAL ACTIVITIES OF DAILY LIVINGAsk the patient these six questions: Are you able to go shopping for groceries or clothes Are you able to bathesponge bath, tub bath or shower? 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? If the patient answers no to any of these questions AND they do not have adequate help.( Positive ( Negative ( Social Work Referral ( ___________________ ( Performed at another time, see progress note dated ____________9. 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