Practical Geriatric Assessment

Health & Wellness

Practical Geriatric Assessment

To be completed by patient or caregiver

Please complete the form below to help us better understand your health needs. All responses are kept confidential and shared only with your care team.

Please answer all required questions —
questions still need a response.

How many times have you fallen in the last 6 months?

Please answer this question.

Mobility & Daily Activities

Does your health limit you in walking one block?

Not limited at all
Limited a little
Limited a lot

Please answer this question.

Does your health now limit you in climbing one flight of stairs?

Not limited at all
Limited a little
Limited a lot

Please answer this question.

Can you get to places out of walking distance…

Without help (drive your own car, or travel alone on buses or taxis)
With some help (need someone to help you or go with you when traveling)
Are you unable to travel unless emergency arrangements are made for a specialized vehicle like an ambulance?

Please answer this question.

Can you go shopping for groceries or clothes (assuming you have transportation)…

Without help (taking care of all shopping needs yourself, assuming you had transportation)
With some help (need someone to go with you on shopping trips)
Are you completely unable to do any shopping?

Please answer this question.

Can you prepare your own meals…

Without help (plan and cook all meals yourself)
With some help (can prepare some things but unable to cook full meals yourself)
Are you completely unable to prepare any meals?

Please answer this question.

Can you do your housework…

Without help (can clean floors, etc.)
With some help (can do light housework but need help with heavy work)
Are you completely unable to do any housework?

Please answer this question.

Can you take your own medicines…

Without help (in the right doses at the right time)
With some help (able to take medicine if someone prepares it for you and/or reminds you)
Are you completely unable to take your medicines?

Please answer this question.

Can you handle your own money…

Without help (write checks, pay bills, etc.)
With some help (manage day-to-day buying but need help managing your checkbook and paying bills)
Are you completely unable to handle money?

Please answer this question.

Can you get in and out of bed…

Without any help or aids
With some help (either from a person or with the aid of some device)
Are you totally dependent on someone else to lift you?

Please answer this question.

Can you dress and undress yourself…

Without any help (able to pick out clothes, dress and undress yourself)
With some help
Are you completely unable to dress and undress yourself?

Please answer this question.

Can you take a bath or shower…

Without help
With some help (need help getting in and out of the tub or need special attachments)
Are you completely unable to bathe yourself?

Please answer this question.

General Wellbeing

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?

All of the time
Most of the time
Some of the time
A little of the time
None of the time

Please answer this question.

How is your eyesight (with glasses or contacts)?

Excellent
Good
Fair
Poor
Totally blind

Please answer this question.

How is your hearing (with a hearing aid, if needed)?

Excellent
Good
Fair
Poor
Totally deaf

Please answer this question.

Check the answer that best describes how you felt over the past week.

Are you basically satisfied with your life?

Yes
No

Please answer this question.

Do you often get bored?

Yes
No

Please answer this question.

Do you often feel helpless?

Yes
No

Please answer this question.

Do you prefer to stay at home rather than going out and doing new things?

Yes
No

Please answer this question.

Do you feel pretty worthless the way you are now?

Yes
No

Please answer this question.