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PHQ-2: Initial Screening

Over the past two weeks, how often have you been bothered by any of the following problems?

	Not at All	Several Days	More than half the days	Nearly every day
Little Interest or pleasure in doing things	0	1	2	3
Feeling down, depressed or hopeless	0	1	2	3

Total Score: __________ If = or >3 go on to PHQ-9

Activities of Daily Living (IADL)

Information obtained from Patient _____ Information obtained from other person ______ Who? ________________

Using Telephone	I = Able to look up numbers, dial, receive and make calls without help A = Able to answer phone or dial operator in an emergency but needs special phone or help in getting number, dialing D = Unable to use telephone
Traveling	I = Able to drive own care or travel alone on buses, taxis A = Able to travel but needs someone to travel with D = Unable to travel
Shopping	I = Able to take care of all food/clothes A = Able to shop but needs someone to shop with D = Unable to Shop
Preparing Meals	I = Able to plan and cook full meals A = Able to prepare light foods but unable to cook full meals alone D = Unable to prepare any meals
Housework	I = Able to do heavy housework, (ie. scrub floors) A = Able to do light housework, but needs help with heavy tasks D = Unable to do any housework
Taking Medicines	I = Able to prepare/take medications in the right dose at the right time A = Able to take medications, but needs reminding or someone to prepare them D = Unable to take medications
Managing Money	I = Able to manage buying needs, (ie. write checks, pay bills) A = Able to manage daily buying needs but needs help managing checkbook, paying bills D = Unable to manage money

I= Independent A = Assistance Required D = Dependent

Hearing

Do you have a hearing problem now? o YES o NO

Safety & Fall Risk Assessment

1.	Have you falling the past 6 months?	YES	NO
2.	If you answered YES to question #1, were you injured?	YES	NO
3.	Have you experienced urgency or frequency with elimination in the past 6 months?	YES	NO
4.	Have you experienced episodes of dizziness in the past 6 months?	YES	NO
5.	Do you use any assistive devices for ambulation? If you answered YES, please circle the device(s) used: a) another person; b) railing; c) cane; d) walker; e) wheelchair	YES	NO
6.	Do you feel you could benefit from installing grab bars on your tub and/or shower?	YES	NO
7.	Does your home lack smoke detectors or sprinklers?	YES	NO
8.	Do you sometimes forget to fasten your seat belt when traveling in a car?	YES	NO
9.	Does your home have a fireplace?	YES	NO
10.	Do you smoke?	YES	NO
11.	Do you drink alcohol at least twice a week?	YES	NO
12.	Do you use oxygen on a regular basis?	YES	NO
13.	Does you home lack fire extinguishers?	YES	NO
14.	Do you use scatter rugs throughout your home?	YES	NO
15.	Does you home have a pool or hot tub?	YES	NO