Appendix A

Appendix A Long-Term Care Comprehensive Geriatric Assessment Form WNL = Within Normal Limits IND = Independent

ASST = Assisted DEP = Dependent

Chief lifelong occupation:______________

Cr Cl/eGFR: ________________

Education: (years)______

Infection Control Behaviours Cognitive Status Emotional † MRSA † WNL † WNL † ÈMood † Verbal Non-aggressive † VRE † Dementia † Depression † Anxiety † Verbal Aggressive † Flu shot given † Delirium † Other † Physical Non-aggressive † Pneumococcal vaccine given MMSE ________ †  Hall/Delusions † Physical Aggressive † TB test done Date__________ † Tetanus/Diphteria Footcare needed Dental care needed Communication: † Y † N † Y † N Speech Hearing Vision † WNL † WNL † WNL Skin Integrity Issues † Y † N † Impaired † Impaired † Impaired Strength Legal NoK:_______________________ † WNL † Weak Upper: PROXIMAL DISTAL R L Lower: PROXIMAL DISTAL R L Advanced Directives † Y † N Transfers IND ASST Dep IND Slow ASST Dep Mobility Walking ____________________ Aid Code Status † Do Not Attempt to Resuscitate Balance WNL Impaired Balance † Do Not Hospitalize Falls N Y Frequency † Resuscitate Bowel CONSTIP CONT INCONT Elimination Bladder CATHETER CONT INCONT Marital Status Family Stress Weight STABLE LOSS GAIN Nutrition † Married † None Appetite WNL FAIR POOR † Divorced † Low Feeding IND ASST Dep † Widowed † Moderate Bathing IND ASST Dep ADLs † Single † High Dressing IND ASST Dep IND ASST Dep Toileting

Problems/Past history

Medication adjustment required. Associated Medication

1. ________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________ 5. ________________________________________ 6. ________________________________________ 7. ________________________________________ 8. ________________________________________ 9. ________________________________________ 10. ______________________________________ 11. ______________________________________ 12. ______________________________________ 13. ______________________________________ 14. ______________________________________ 15. ______________________________________ Current Frailty Score Scale 1. Mildly frail 2. Moderately frail

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3. Severely frail

4. Very severely ill

Physician: ____________________________ CD0184MR_06_

5. Terminally ill Date: ____________

YYYYMMDD © 2007-2008 All rights reserved. Geriatric Medicine Research, Dalhousie University.Halifax, Canada. Used with permission