Two Page Simple Geriatric Screen printable pdf download

TWO PAGE SIMPLE GERIATRIC SCREEN

Patient Name ____________________________

Date ________________________

Source: Pt ________ Other ___________________

Abnormal

Action

Result and Comments

HISTORY ITEMS

"Have you had any falls in the last year?"

Yes

Tinetti or other gait assessment

________________________

Further exam, Home eval & PT

Consider osteoporosis risk

"Do you have trouble with stairs, lighting,

Yes to any

Home eval &/or PT

________________________

bathroom, or other home hazards?"

"Do you have a problem with urine leaks

Yes

Rule out reversible (DIAPPERS)

or accidents?

History (stress, urge), exam, PVR

________________________

"Over the past month, have often been bothered by

feeling sad, depressed, or hopeless?”

Yes to either

GDS or other depression assessment

________________________

“During the past month, have you often been bothered by

little interest or pleasure in doing things?

Do you ever feel unsafe where you live?

Yes

Explore further, social work, APS

________________________

Does anyone threaten you or hurt you?

Is pain a problem for you?

Yes

Comments

____________________________________________

Do you have any problems with any of the following areas? Who assists?/ do you use any devices? (for "yes" answers, consider causes, social services

and/or home eval/PT/OT)

Doing strenuous activities like fast walking/bicycling?