Staywell annual health review questionnaire

Section

Social life

Do you live on your own?
Do you have an emergency care line?
Do you see family/friends on a regular basis?
Do you ever feel lonely or sad?
Do you find it difficult to go out by yourself?

Looking after yourself

Do you receive attendance allowance?
Do you have a carer or relative helping you at home?
Is it an agency?
Are you a carer?
Do you feel you have adequate support?
Do you need help or struggle with any of the following – washing, getting dressed, going to the toilet, cooking, cleaning, laundry?
Do you have a physical disability that limits these activities?
Would you like to be referred for information on local services that you may be able to access e.g. local transport, help in the community, meals on wheels?

Mobility/safety

Has there been any changes in your mobility or energy in the last year?
Have you fallen in the last six months?
Do you have any aids to help you mobilise around the house/outside e.g. walking stick, zimmer, chair lift?
Is there anything that you particularly struggle with around the house e.g. stairs, front door, getting off the toilet, sofa?
Do you have a blue badge?
Do you have any significant problems with your hearing or eyesight?
Do you get regular check ups?

General Health

Is there anything about your health at present which is causing you any concern or difficulty?
Do you have any continence problems?
Have you had any professional advice?
Do you understand all the medication you are taking?
Do you ever forget to take your medication?
Do you or your family have any concerns about your memory?

Dementia is nothing to be ashamed of. It is a good idea to seek advice and help as early as possible.

To talk about any concerns in confidence, you can contact Managing Memory 2gether by calling 0800 694 8800 or mention it to a health professional at the Phoenix Surgery.

Smoking

Have you ever smoked?
Do you still smoke?
Would you like advice to help you stop smoking?

Clinical frailty scale

1. Very fit – people who are robust, active, energetic and motivated. They commonly exercise regularly and are among the fittest for their age

2. Well – people who have no active disease symptoms but are less fit than category 1. Typically, they exercise or are very active occasionally, such as seasonally

3. Managing well – people whose medical problems are well controlled but are not regularly active beyond routine walking

4. Vulnerable – while not dependent on others for daily help, often symptoms limit activities. A common complaint is being ‘slowed up’ and/or being tired during the day

5. Mildly frail – these eople often have more evident slowing and need help with high-order IADLs. Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework

6. Moderately frail – People need help with all outside activities, housework and cooking. They often need help with stairs and bathing, and might need minimal assistance with dressing

7. Severely frail – people completely dependent for personal care. However, they seem stable and not at high risk of dying (within approximately 6 months)

8. Very severely frail – people completely dependent and approaching the end of life. Typically, they could not recover even from a minor illness

9. Terminally ill – people approaching the end of life. This category applies to people with a life expectancy of more than 6 months, who are not otherwise evidently frail

IADL = instrumental activity of daily living (such as finances, transport, heavy housework or medications)

Scoring frailty in people with dementia

The degree of frailty corresponds to the degree of dementia. Common symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal.

In moderate dementia, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting.

In severe dementia, they cannot do personal care without help.

Where would you place yourself on the clinical frailty scale?

Final Questions

Did you fill this questionnaire in by yourself?
How happy are you with your current situation and quality of life?
10 = happy, 0 = not happy