DENVER VA GERIATRICS SCREEN
Reason for Consultation:
RECOMMENDATIONS:
Problem List:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Medications:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Recently discontinued medications:
1.
2.
3.
Over-the-counter/herbal medications:
1.
2.
3.
4.
Patient's understanding of indication for each medication:
[]All:
[]>50%:
[]<50%:
[]None:
"Sometimes people forget miss their medication, forget to take them, or
take extra pills if they think they need them.
Does this ever happen to you?"
[]Never; []<once/month []<once/week;
[]>once a week or daily
Side effects of medication: "Do you have any of the following symptoms? Do
you think they might be related to your medications?"
Urinary freq:
Dry mouth:
Sleepy:
Gl problem:
Dizzy:
Sex problem:
Other (specify):
[
[
[
[
[
[
[
]
]
]
]
]
]
]
FUNCTIONAL STATUS
Vision: []
[]
[]
[]
[]
Normal
Impaired
Interferes w/ function
Cataract
Glaucoma
Hearing: [] Normal
[] Impaired;
[] Interferes w/ function
[] Hearing aid
Dentition: []
[]
[]
[]
Dentulous (most, half, few teeth present)
Edentulous
Dentures (good fit, poor fit)
Interferes with function
Ambulation: []
[]
[]
[]
[]
Independent
[] Cane
[] Rolling walker
Standard walker
[] Standard crutches
Lofstran crutches [] Wheelchair
[] Bedridden
Other assistive device
Interferes with function
Continence: Bowel ([] continent, []occasionally incont,
[] Interferes with function
[]incont.)
Bladder ([] continent, [] occasionally incont, [] incont.)
[] interferes with funct
ADL:
Independent
Bathing
[]
Dressing
[]
Feeding
[]
Toileting
[]
Meal prep
[]
Medications
[]
Shopping
[]
Telephone
[]
Housekeeping
[]
Laundry
[]
Finances
[]
Needs assist
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
Dependent
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
SAFETY: (e.g., stairs, stove, etc.)
[] Endangers self freq;
[] occas;
[] never
DRIVING: Patient drives motor vehicle: [] yes; [] no
visual acuity 20/
FALL RISK: falls within 6 months [] yes; [] no
Get-up-and-go test: [] normal;
Comment:
[] impaired
Glabellar response: [] nl;
Palmomental: [] present;
[] abn
[] absent
Rhomberg test:
Comment:
[] abn
[] nl;
SOCIAL:
Living situation: []
[]
[]
[]
[]
number:
alone
[] spouse
Family (specify):
Assisted living (name)
Nursing home (name)
Other:
Caregiver/support system:
Name:
Relationship:
Proximity:
Phone #:
[] yes; [] no "Do you need more help at home?"
Comment:
[] yes; [] no "Do you have enough money to buy food, pay bills and to
obtain transportation?"
Comment:
NUTRITION (score, i.e., # answered true: _/8)
Serum Albumin:
[]
[]
[]
[]
[]
[]
T/F:
T/F:
T/F:
T/F:
T/F:
T/F:
I don't always have enough money to buy food.
I eat fewer than 2 meals per day.
I have tooth or mouth problems that make it hard to eat.
Without trying, I have lost 10 lbs or more in the last 6 mos.
I eat few fruits, vegetables or milk products.
I have an illness that made me change the kind or amount
of food I eat.
[] T/F: I have 3 or more drinks of beer/liquor/wine almost every day.
[] T/F: I am not always physically able to shop, cook and/or feed myself.
SKIN INTEGRITY:
PSYCHIATRIC:
Sleep:
Interest:
Guilt:
Energy:
Concentration:
Appetite:
Psychomotor:
Sucidality:
Breakdown [] yes; [] no
Sites/description:
[]
[]
[]
[]
[]
[]
[]
[]
Nl
Nl
Nl
Nl
Nl
Nl
Nl
Yes
[]
[]
[]
[]
[]
[]
[]
[]
Abn
Abn
Abn
Abn
Abn
Abn
Abn
No
comment:
comment:
comment:
comment:
comment:
comment:
comment:
comment:
Geriatric Depression Screen: __/15 or __/30
PREVENTION/HEALTH MAINTENANCE:
Immunizations: pneumovax
Influenza
Tetanus
PPD:
Mammogram: [] Yes; [] No
Tobacco: [] never;
[]
[]
[]
[]
Yes;
Yes;
Yes;
Yes;
[] n.a.
[] previous;
Alcohol: [] Cut back;
[]
[]
[]
[]
No
No
No
No
date:
date:
date:
date:
Pap smear: [] Yes; [] No
[] current
[] Annoyed;
[] "Guilt;
[] n.a.
packs/day:
[] Eye opener
ADVANCED DIRECTIVES:
[] Living will
[] Cor Status
[] Durable POA (specify):
Comment:
MINI-MENTAL STATUS EXAM:
If no, describe:
Alert ([] yes;
[] no)
ORIENTATION: score
__/10
(year/season/date/day/month) (state/county/town/hospital/floor)
REGISTRATION: score /3
(name 3 objects; patient repeats each. Then repeat all 3 for scoring)
ATTENTION/CALCULATIONS: score /5
(serial 7s, counting backward from 100. Stop after 5 answers.
If < high school education, spell "world" backwards)
RECALL: score /3
(approximately 5 minutes after registration)
LANGUAGE: score /9
Name pencil and watch (2 points)
Repeat "no ifs, ands or buts" (one point)
Three stage command ("take this paper in your right hand, fold it in half,
put it on the table") (3 points)
Read and obey: "Close your eyes" (1 point)
Write a sentence. (1 point)
Copy design. (1 point)
TOTAL: /30
EXAM:
LABS:
IMPRESSION:
Level of education: