Cognition: Please imagine that this pre - drawn circle is a clock. I would like you to place the numbers in the correct positions then place the hands to indicate a time of ‘ten after eleven’
Minor spacing errors
General health status: In the past year, how many times have you been admitted to a hospital?
In general, how would you describe your health?
Excellent’, ‘Very good’, ‘Good’
Functional independence: With how m any of the following activities do you require help? (meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications)
0 - 1
2 - 4
Social support: When you need help, can you count on someone who is willing and able to meet your needs?
Medication use: Do you use five or more different prescription medications on a regular basis?
At times, do you forget to take your prescription medications?
Nutrition: Have you recentl y lost weight such that your clothing has become looser?
Mood: Do you often feel sad or depressed?
Continence: Do you have a problem with losing control of urine when you don’t want to?
Functional performance: I would like you to si t in this chair with your back and arms resting. Then, when I say ‘GO’, please stand up and walk at a safe and comfortable pace to the mark on the floor (approximately 3 m away), return to the chair and sit down’
0 - 10
11 - 20
One of : >20 s , or patient unwilling , or requires assistance
Final score is the sum of column totals: Total [__/17] =