Daily functional ability

Degree of difficulty eating, dressing, bathing, transferring between bed and chair, using the toilet, and controlling bladder and bowel

Degree of difficulty preparing meals, doing housework, taking medications, going on errands (eg, shopping), managing finances, and using the telephone

Assistive devices

Use of personal devices (eg, cane, walker, wheelchair, oxygen)

Use of environmental devices (eg, grab bars, shower bench, hospital bed)

Caregivers

Use of paid caregivers (eg, nurses, aides)

Use of unpaid caregivers (eg, family members, friends, volunteers)

Medications

Name of prescription medications used

Name of nonprescription medications used

Nutrition

Height, weight

Stability of weight (eg, "Has the patient lost 4.54 kg [10 lb] in the past 6 months without trying?")

Preventive measures

Regularity of blood pressure measurements, guaiac test for occult blood in stool, sigmoidoscopy or colonoscopy, immunizations (influenza, pneumococcal, tetanus), thyroid-stimulating hormone assessment, and dental care

Regularity of exercise

Use of smoke detectors

Cognition

Ability to remember 3 objects after 1 minute and draw a clock face (Mini-Cog^©)

Affect

Feelings of sadness, depression, or hopelessness

Lack of interest or pleasure in doing things

Advance directives

Possession of a living will

Establishment of durable power of attorney for health care

Substance abuse/misuse

Gait and balance

Number of falls in the past 6 months

Time required to rise from a chair, walk 3.05 meters (10 feet), turn around, return, and sit down

Extent of maximal forward reach while standing

Sensory function

Ability to report 3 numbers whispered 0.61 meters (2 feet) behind the head

Ability to read Snellen chart at 20/40 or better (with corrective lenses, if needed)

Upper extremity mobility

Ability to clasp hands behind the head and back