Basic Information About You

1.    Full Name   Mr.    Mrs.    Miss    Ms. (circle one)     _________________________________________

2.    Date of Birth  ______________________________

3.    Marital Status  (circle one)        Never married        Married        Widowed        Divorced        Separated

4.    Usual height during your life        _________ feet  _________  inches

5.    Usual weight during your life        _________ pounds       

6.    Approximate weight now    ______ pounds        Approximate weight one year ago    ______ pounds

7.    Do you have any advance directives (circle ALL that apply)?

        Do Not Resuscitate        Health Care Proxy        Living Will        Power of Attorney        Regular Will

8.    How would you rate your overall health compared to one year ago (circle the ONE best answer)?

        About the same            Improved            A little worse            A lot worse

9.    Has any of the following happened to you over the past year (circle ALL that apply)?

        Death of a close friend or relative        Death of a pet        Fall        Heart attack        Stroke

        Elective surgery        Emergency surgery        Emergency room visit        Hospital stay

10.    What is the name of your primary care physician?    _______________________________________

        Approximately how many times have you seen him/her in the past year?    ______  visits

        What was the date of your last visit?    _______________________________

11.    What is your general attitude about your life right now (circle ALL that apply)?

        I look forward to each day        I don't care if I die tomorrow        I'm depressed        I'm happy

        I'm lonely        I like to keep to myself        I wish someone would call or visit more often

        I'm afraid of dying        I'm not afraid of dying        My faith helps keep me going

12.    Which of the following do you usually do at least once a week (circle ALL that apply)?

        I drive        I have a paying job        I volunteer        I get out and socialize with others        I write letters

        I read        I watch TV        I listen to music (tapes, CD's or records)        I listen to the radio

13.    What is your general attitude about the future (circle the ONE best answer)?

        Afraid        I take one day at a time        I thing something bad will happen        I look forward to it

Copyright 2004.  Robert S. Stall, MD / Stall Geriatrics.  All Rights Reserved.