GERIATRIC ASSESSMENT
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Your Daily Activities
PATIENT INSTRUCTIONS: Indicate your response by marking an X in one box per question.
Can you use the telephone...
without help, including looking up and dialing;
with some help (can answer phone or dial operator in an emergency, but need a special phone or help in getting the number or dialing); or
are you completely unable to use the telephone?
 
Can you get to places out of walking distance...
without help (can travel alone on busses, taxis, or drive your own car);
with some help (need someone to help you or go with you when traveling); or
are you unable to travel unless emergency arrangements are made for a specialized vehicle like an ambulance?
 
Can you go shopping for groceries or clothes (assuming you have transportation)...
without help (taking care of all shopping needs yourself, assuming you have transportation);
With some help (need someone to go with you on all shopping trips); or
are you completely unable to do any shopping?
 
Can you prepare your own meals...
without help (plan and cook full meals yourself);
with some help (can prepare some things but unable to cook full meals yourself); or
are you completely unable to prepare any meals?
 
Can you do your housework...
without help (can clean floors, etc.);
with some help (can do light housework but need help with heavy work); or
are you completely unable to do any housework?
 
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 to take it); or
are you completely unable to take your medicines?
 
Can you handle your own money...
without help (write checks, pay bills, etc.);
with some help (manage day-to-day buying but need help with managing your checkbook and paying your bills); or
are you completely unable to handle money?
 
Does your health limit you in these activities?
The following items are activities you might do during a typical day. Does your health limit you in these activities? (Mark an X in the box on each line that best reflects your situation.)
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
Limited a lot
Limited a little
Not limited at all
 
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
Limited a lot
Limited a little
Not limited at all
 
Lifting or carrying groceries
Limited a lot
Limited a little
Not limited at all
 
Climbing several flights of stairs
Limited a lot
Limited a little
Not limited at all
 
Climbing one flight of stairs
Limited a lot
Limited a little
Not limited at all
 
Bending, kneeling, or stooping
Limited a lot
Limited a little
Not limited at all
 
Walking more than a mile
Limited a lot
Limited a little
Not limited at all
 
Walking several blocks
Limited a lot
Limited a little
Not limited at all
 
Walking one block
Limited a lot
Limited a little
Not limited at all
 
Bathing or dressing yourself
Limited a lot
Limited a little
Not limited at all
 
Current Health Rating
Which one of the following phrases best describes you at this time?
 
Falls
How many times have you fallen in the last 6 months?
 
Medications
Are you taking any medications?
Yes  No
How many prescribed medications are you taking?
 medications
How many over-the-counter medications are you taking?
 medications
How many herbs and vitamins are you taking?
 herbs and vitamins
 
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