Currently UseWould Like to Start Using if AvailableDon'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
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.