Appendix 15Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: patient baseline initial interview form
This section is to be completed from the medical notes of the participant and by direct interview.
View in own window
| Date | |
|---|
| Gender | Male □ Female □ |
| Consent type | Consent □ Carer consultee □ Medical practitioner consultee □ |
| Cognition |
|---|
| MMSE – not reproduced for copyright reasons |
| Result of the AMU assessment (as listed in the records). This may be a diagnosis (i.e. a disease), a problem (e.g. a fall) or a symptom (e.g. chest pain). Record diagnoses if made; only record problems or symptoms if not |
| Assessed by Assessed by Front door Assessment and Co-ordination Team (FACT)/crisis response | Yes □ No □ |
| Medications |
|---|
| Drug | Dose | Frequency | Route |
|---|
| Total number of different prescription medications taken each day |
| Did the patient present with any of the following? |
|---|
| Weight loss | Yes □ No □ |
| Fall | Yes □ No □ |
| Reduced mobility | Yes □ No □ |
| New or increased continence disorder | Yes □ No □ |
| Current pressure sores | Yes □ No □ |
| Dehydration | Yes □ No □ |
| Cognitive impairment/confusion | Yes □ No □ |
| Has the participant ever had any of the following medical conditions? |
|---|
| Myocardial infarct | Yes □ No □ |
| Congestive heart failure | Yes □ No □ |
| Peripheral vascular disease | Yes □ No □ |
| Cerebrovascular disease | Yes □ No □ |
| Dementia | Yes □ No □ |
| Chronic pulmonary disease | Yes □ No □ |
| Short of breath | Yes □ No □ |
| Connective tissue disease | Yes □ No □ |
| Ulcer disease | Yes □ No □ |
| Mild liver disease | Yes □ No □ |
| Moderate or severe liver disease | Yes □ No □ |
| Diabetes | Yes □ No □ |
| Hemiplegia | Yes □ No □ |
| Moderate or severe renal disease | Yes □ No □ |
| Diabetes with end-organ damage | Yes □ No □ |
| Any tumour | Yes □ No □ |
| Leukaemia | Yes □ No □ |
| Lymphoma | Yes □ No □ |
| Metastatic solid tumour | Yes □ No □ |
| AIDS | Yes □ No □ |
