OldSmarts™ Quality of life assessment Complete, print, and bring to any visit you have with a health professional. OldSmarts™ Quality of Life Assessment OldSmarts™ Quality of Life Assessment Basic info Pt ID (assigned by your doctor's practice) Practice/Physician/Group Date form completed Visit type Existing patient visit New patient visit OtherOther Patient date of birth Patient sex Female Male OtherOther Ethnicity White Black Latino Asian Native American Non-native American Mixed OtherOther Completed by Self Spouse/partner Son Daughter Grandchild Friend Aide Nurse PT/OT OtherOther Email address if you would like a copy of the report Events - things that have happened to you since your last visit (existing patient) or in the past year (new patient) Called your PCP office No Yes Called a specialist office No Yes Car accident No Yes Death of a spouse No Yes Death of other close relative No Yes Death of a friend No Yes Death of a pet No Yes ER visit No Yes Fall No Yes Hospital stay No Yes Moved No Yes New device (cane, walker, wheelchair) No Yes New non-prescription medication or supplement No Yes New prescription medication No Yes Outpatient rehab No Yes PCP visit No Yes Rehab stay No Yes Specialist visit No Yes Stopped a medication on your own No Yes Stopped driving No Yes Surgery - elective No Yes Surgery - emergency No Yes Test done (blood, xray) No Yes Urgent care visit No Yes Issues - how you felt most days in the past week Anxiety/stress Not a problem Somewhat a problem Significant problem Intolerable Caring for someone else Not a problem Somewhat a problem Significant problem Intolerable Chest pain or pressure Not a problem Somewhat a problem Significant problem Intolerable Constipation Not a problem Somewhat a problem Significant problem Intolerable Difficulty walking Not a problem Somewhat a problem Significant problem Intolerable Dizziness Not a problem Somewhat a problem Significant problem Intolerable Fear of death Not a problem Somewhat a problem Significant problem Intolerable Fear of disability or being a burden Not a problem Somewhat a problem Significant problem Intolerable Fear of falling Not a problem Somewhat a problem Significant problem Intolerable Indigestion/nausea Not a problem Somewhat a problem Significant problem Intolerable Loneliness/boredom Not a problem Somewhat a problem Significant problem Intolerable Low energy Not a problem Somewhat a problem Significant problem Intolerable Low mood Not a problem Somewhat a problem Significant problem Intolerable Managing your health problems Not a problem Somewhat a problem Significant problem Intolerable Managing your medications Not a problem Somewhat a problem Significant problem Intolerable Memory loss Not a problem Somewhat a problem Significant problem Intolerable Overall health/quality of life Not a problem Somewhat a problem Significant problem Intolerable Pain Not a problem Somewhat a problem Significant problem Intolerable Poor appetite Not a problem Somewhat a problem Significant problem Intolerable Poor sleep Not a problem Somewhat a problem Significant problem Intolerable Sex life Not a problem Somewhat a problem Significant problem Intolerable Shortness of breath Not a problem Somewhat a problem Significant problem Intolerable Unintentional weight loss Not a problem Somewhat a problem Significant problem Intolerable Unsteadiness Not a problem Somewhat a problem Significant problem Intolerable Urine leakage/incontinence Not a problem Somewhat a problem Significant problem Intolerable Worries/regrets Not a problem Somewhat a problem Significant problem Intolerable Wishes - what are ONE or TWO main things that would make your life better (besides good health and money)? Wishes Scores Past events score (max 24) - how many significant things have happened to you recently % of max Issues score (max 78) - how much things are bothering you % of max Recent Significant Events References Death of other close relative - check out How to cope with death the first time you lose someone close, Bereavement, and Grief: Coping with the loss of your loved one Called your PCP office - check out A Doctor’s Guide to a Good Appointment Called a specialist office - check out Many Patients Don't Pursue Referrals Car accident - check out Older Drivers Death of a spouse - check out Mourning the Death of a Spouse Death of a friend - check out Coping with the Death of a Friend Death of a pet - check out 7 Self-Care Essentials While Grieving the Death of a Pet, Coping with the loss of a pet, and Why We Need to Take Pet Loss Seriously ER visit - check out ER Trip May Point to Other Issues for Older Adults and Top 10 Reasons Seniors Go to the ER Fall - check out Falls in Older People, Falls in the Elderly, What Causes Falls in the Elderly? How Can I Prevent a Fall?, and Deaths From Falls by Older Adults Sharply Increase Hospital stay - check out The Psychological Effect of a Hospital Stay on Seniors, After Hospitalization, Mental Trouble for Elderly Patients and For elderly patients, hospital stays often worsen disabilities Moved - check out A Moving Concern: Transitional Trauma New device - check out Geriatric Assistive Devices and Assistive Technology Helps People Age in Place New non-prescription medication or supplement - check out Dietary Supplements for Older Adults New prescription medication - check out Drug-Related Problems in Older Adults Outpatient rehab - check out Physical Therapy for Seniors, The Benefits of Physical Therapy for Older Adults, and 4 Types of Physical Therapy for Seniors PCP visit - check out Why Don’t Patients Follow Their Doctors’ Advice? Rehab stay - check out 13 Things to Know About Sub Acute Rehab, What is Subacute Nursing Home Care? and Senior Rehabilitation Centers: Better Care Options After a Hospital Stay Specialist visit - check out When Do You Need a Specialist Doctor? Stopped driving - check out We Need to Talk: The Difficult Driving Conversation Stopped a medication on your own - check out Not Taking Medication as Prescribed Harms Senior Health and The Top 6 Reasons Elderly People Don't Take Medication Surgery - elective - check out Study: Frailty in seniors raises mortality risk related to elective surgery, Is Surgery Right for Your Older Loved One?, Avoiding Surgery in the Elderly, and Elderly Patients and Surgical Risk Surgery - emergency - check out Emergency surgery in the elderly: challenges and solutions Test done - check out Medical Tests in your 60s and Up and Top 10 Blood Tests for Older Adults: What to Know Urgent care visit - check out Emergency Rooms Are No Place for the Elderly babdgfaga Great, no significant events recently - if any of the above happens, make sure your PCP knows! Significant or Intolerable Issues References Anxiety/stress - check out Anxiety & Older Adults, Elder Abuse, and Crimes Against Seniors Caring for someone else - check out 7 Tips to Avoid Caregiver Burnout Chest pain or pressure - check out Heart Health Constipation - check out Concerned About Constipation? Difficulty walking - check out Gait and Balance Disorders in Older Adults Dizziness - check out Dizziness and Vertigo Fear of death - check out 6 Positive Ways To Overcome Your Fear Of Death Fear of disability or being a burden - check out 5 Signs That Your Biggest Fear is ‘Being a Burden’ Fear of falling - check out Prevent Falls and Fractures, 5 Ways to Ease Your Fear of Falling, and Why Do Older Adults Have More Falls? Indigestion/nausea - check out Indigestion Loneliness/boredom - check out Easing Old People's Loneliness Can Help Keep Them Healthy Low energy - check out Fatigue in Older Adults Low mood - check out Depression and Older Adults Managing your health problems - check out Health Screening Managing your medications - check out Taking Medicines Safely as You Age and Saving Money on Medicines Memory loss - check out Do Memory Problems Always Mean Alzheimer's Disease? and Basics of Alzheimer's Disease and Dementia Overall health/quality of life - check out Quality of life and 10 Things You Can Do to Improve Your Life Right Now Pain - check out Pain: You Can Get Help Poor appetite - check out Healthy Eating and Taking Care of Your Teeth and Mouth Poor sleep - check out A Good Night's Sleep and Aging Changes In Sleep Sex life - check out Sexuality and Intimacy in Older Adults Shortness of breath - check out COPD Unintentional weight loss - check out Unintentional Weight Loss in Older Adults Unsteadiness - check out Gait and Balance Disorders in Older Adults Urine leakage/incontinence - check out Urinary Incontinence in Older Adults Worries/regrets - check out and The 25 Biggest Regrets In Life. What Are Yours? and The Most Surprising Regret Of The Very Old — And How You Can Avoid It Great, no significant or intolerable issues right now - if anything develops, make sure you let your PCP know! Copyright 2022 OldSmarts LLC If you are human, leave this field blank. Δ