Senior Living: Medical Questionnaire for Seniors

Sleep deprivation may be a risk factor for many common medical problems, including weight gain, diabetes and hypertension. more...

Medical Questionnaire for Seniors

Before seeing your physician, you might want to print out and then complete the following series of 5 questionnaires. It will help your doctor and you better manage your medical needs. Answer as many questions as you can.

Name

Age

Blood Pressure

laying down
standing

Weight

now
6 months ago
difference

Height

at age 20
now

Cholesterol

LDL
HDL

Vaccinations
Influenza (yearly)
Pneumococcal
Tetanus (every 10 years)

TSH
Date

Fasting Glucose
Date

Do you smoke?
Yes
No

How much alcohol do you drink?
per day

Do you use a seatbelt?
Yes
No

Do you chew tobacco?
Yes
No

Exercise
How often per week do you...

do endurance exercises (walk briskly 20 to 30 minutes/day or climb 10 flights of stairs)
do resistance exercises?
do balance exercises?
do posture exercies?
do flexibility exercises?

Can you see adequently in poor light?
Yes
No

Can you hear in a noisy environment?
Yes
No

Are you incontinent?
Yes
No

Have you a living will or durable power of attorney for health?
Yes
No

Do you take aspirin daily (only if you have had a heart attack or have diabetes)?
Yes
No

Do you have any concerns about your personal safety?
Yes
No

When did you last have your stool tested for blood?

When were you last screened for osteoporosis?

Are you having trouble remembering things?
Yes
No

Do you have enough food?
Yes
No

Are you sad?
Yes
No

Do you have pain?
Yes
No

If so, which face best describes your pain?

Male

Do you have trouble passing urine?
Yes
No

Have you discussed PSA testing with your doctor?
Yes
No

What is your ADAM score?

Female

When was your last pap smear?

When was your last mammogram?

Do you check your breasts monthly?
Yes
No

Are you satisfied with your sex life?
Yes
No

Geriatric Depression Scale	ADAM (men only)
CAGE	Epworth Sleepiness Questionnaire

This questionnaire is based on the health promotion and prevention guidelines developed by Gerimed^TM and Saint Louis University Division of Geriatric Medicine.

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