Point Criteria | Maximum 34 Points | |
---|---|---|
In general, would you say your health is:  ▪ Excellent = 0  ▪ Very Good = 0.25  ▪ Good = 0.5  ▪ Fair = 0.75  ▪ Poor = 1 | 1 point | |
How much does your physical health interfere with your work or other regular daily activities?  ▪ Not at all = 0  ▪ A Little Bit = 0.25  ▪ Moderately = 0.5  ▪ Quite a bit = 1 | 1 Point | |
How much does your emotional/mental health interfere with your work or other regular daily activities?  ▪ Not at all = 0  ▪ A Little Bit = 0.25  ▪ Moderately = 0.5  ▪ Quite a bit = 1 | 1 point | |
Chronic diseases = 1 point for each | 9 points | |
 ▪ Diabetes  ▪ Hypertension  ▪ History of Heart disease  ▪ History of Cancer (other than just skin)  ▪ Osteoarthritis | ▪ Osteoporosis ▪ History of Stroke ▪ Parkinson’s Disease ▪ COPD/Bronchitis |  |
Chronic functional health conditions = 1 point for each | 9 points | |
 ▪ Vision problems that interfered with daily activities (driving, reading, etc.)  ▪ Hearing problems and/or deafness  ▪ Urinary leakage  ▪ Depression/Anxiety  ▪ Frequent/ongoing Pain | ▪ Oral health problems making it difficult to eat or talk ▪ Balance or walking problems ▪ Memory problems ▪ Insomnia |  |
Mobility problems: Which of the following describes your situation?  ▪ I usually need help from another person to move around or I usually use a motorized wheel chair = 1  ▪ I usually use a cane, walker or poles = 0.5  ▪ I don’t need help, but have some trouble getting around = 0.25  ▪ I am not limited at all in my ability to get around = 0 | 1 point | |
Help needed with ADLs or IADLs due to a disability, health problem, or frailty due to age = 1 point for each | 11 points | |
ADLs:  ▪ Getting in and out of bed/chairs  ▪ Bathing in a tub or shower  ▪ Dressing  ▪ Eating food/drinking liquids  ▪ Using the toilet | IADLs: ▪ Shopping for groceries ▪ Doing laundry/household chores ▪ Preparing meals ▪ Managing money ▪ Managing/taking your medicines ▪ Using the telephone |  |
Underweight based on Body Mass Index (BMI, kg/m2)  ▪ BMI < 18.5 = 1 BMI ≥ 18.5 = 0 | 1 point |