Health Fair Self-Assessment Booklet

Contents & Instructions

1. Medical Information Privacy Notice (next page)
   (you must read & sign this to participate in the Health Fair)
2. Basic Information About You (page 1)
3. Quality of Life Assessment (page 2)
4. Medication, Immunizations, Alcohol, & Cigarette Use (page 3)
5. Symptom Checklist (page 4)
6. Balance Assessment (page 5)
7. Daily Function Assessment (page 6)
8. Emotional Assessment (page 7)
9. Memory Checklist (page 8)
10. Hearing Checklist (page 9)
11. Vision Checklist (page 10)
12. Nutrition Assessment (page 11)
13. Urine Function Assessment (page 12)
14. Home Safety Checklist (pages 13-14)
15. Sleep Assessment (page 15)
16. Sleep Diary
    (complete for four days before the Health Fair only if you have sleep problems) (page 16)
17. Driving Quiz - Part 1
    (complete only if you drive) (page 17)
18. Driving Quiz - Part 2
    (complete only if you drive) (page 18)
19. Key Principles of Geriatric Care by Robert S. Stall, MD
    (read at your leisure) (page 19)
20. A Story to Remember by Robert S. Stall, MD
    (read at your leisure) (page 20)

Back to The Health Fair

Back to Grassroots Geriatrics^TM
Mobilizing seniors, caregivers, and volunteer organizations to improve care for older adults