| Currently Use | Would Like to Start Using if Available | Don't Care/Don't Need | |
|---|---|---|---|
| Vitals/Patient Measurements | |||
| Health Risk Assessment | |||
| Alcohol Screening | |||
| Tobacco Screening | |||
| Immunizations Checklist | |||
| List of Current Providers | |||
| List of Pharmacies | |||
| List of Medical Suppliers | |||
| Personal Medical History | |||
| Family Medical History | |||
| Depression (PHQ-2) | |||
| Depression (PHQ-9) | |||
| Functional Ability - Questionnaire | |||
| Functional Ability - Physical Test (e.g., TUG) | |||
| Safety - Self Reported Questionnaire | |||
| Cognitive Measures (validated memory screening tool) | |||
| Cognitive Measures (direct observations or family concerns) | |||
| AHRQ Preventive Services Calculator | |||
| Activities of Daily Living Questionnaire | |||
| Quality of Life Questionnaire | |||
| Fall Risk | |||
| Hearing Impairment | |||
| Mobility Assessment | |||
| Physical Activity Level | |||
| Nutrition/Diet Assessment | |||
| Home Safety Assessment | |||
| Driving Safety Assessment | |||
| Drug Use | |||
| Suicide Risk | |||
| Anxiety Disorders | |||
| Trauma | |||
| End-of-Life Checklist | |||
| Other (please specify): | |||
| Other (please specify): | |||
| Other (please specify): |
Abbreviations: PHQ, Patient health questionnaire; TUG, Timed up and go; AHRQ, Agency for healthcare research and quality.