GO SAFE Study DATA COLLECTION SHEET CRF B Baseline evaluation

Go Safe Study Data Collection Sheet Crf B Baseline Evaluation-Free PDF

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GO SAFE Study,Age adjusted G 8, Charlson Comorbidity Index Has food intake 0 severe decrease in. declined over the past food intake, Condition Pts 3 months due to loss 1 moderate decrease. Age 50 0 of appetite digestive in food intake, Age 50 59 1 problems chewing or 2 no decrease in food. Age 60 69 2 swallowing intake,Age 70 79 3 difficulties. Age 80 89 4 Weight loss during 0 weight loss 3 kg,Age 90 99 5 the last 3 months 1 does not know.
Myocardial Infarction 1 2 weight loss,Congestive Heart Failure 1 between 1 and 3 kg. Periferal Vascular Disease or by pass 1 3 no weight loss. Cerebrovascular disease of transient 1 Mobility 0 bed or chair bound. ischaemic disease 1 able to get out of,Hemiplegia 2 bed chair but does not. Pulmonary disease asthma 1 go out,Diabetes 1 2 goes out. Diabetes with end organ damage 2 Neuropsychological 0 severe dementia or. Renal disease 2 problems depression,Mild liver disease 2 1 mild dementia or. Severe liver disease 3 depression,Gastric or peptic ulcer 1 2 no.
neuropsychological,Cancer lymphoma leukemia solid cancer 2. Metastatic solid cancer 6,BMI 0 BMI 18 5,Dementia or Alzheimer s 1. 1 BMI 18 5 to 21,Rheumatic or connective tissue disease 1. 2 BMI 21 to 23,HIV or AIDS 6,Hypertension 1,Takes more than three 0 yes. Skin ulcers cellulitis 1,prescription drugs per 1 no.
Depression 1,Warfarin 1,In comparison with 0 0 not as good. TOTAL SCORE 0 42 other people of the 0 5 does not know. same age how does 1 0 as good,the patient consider 2 0 better. his her health status, Flemish version of Triage Risk Screening Tool Age 0 85. Presence of cognitive impairments disorientation,2 0 Total Score 0 17. dementia delirium,Lives alone or no caregiver willing or able 1 0.
Difficulty with walking or transfer or fall s in the last. Hospitalized in the last 3 months 1 0,Polipharmacy 5 medications 1 0. CRF B final version,GO SAFE Study,EQ 5D 3L VAS ADL. I have no problems in walking about BATHING I Receives no assistance gets. MOBILITY 1,in and out of bath or shower, I have some problems in walking Your health today by self if bath is usual means of. about bathing,I Receives assistance in, I am confined to bed 3 bathing only one part of the. body such as back or leg, SELF CARE I have no problems with self care 1 D Receives assistance in.
bathing more than one part of, I have some problems washing or 2 the body or not bathed. dressing myself DRESSING I Gets clothes and gets,completely dressed without. I am unable to wash or dress myself 3 assistance,I Gets clothes and gets. USUAL I have no problems with performing 1 completely dressed without. my usual activities assistance except for assistance. ACTIVITIES,in tying shoe laces, I have some problems with 2 D Receives assistance in. performing my usual activities,getting clothes or in getting.
I am unable to do my usual activities dressed or stays partly or. completely undressed, I have no pain or discomfort TOILET I Goes to toilet room. cleans self and arranges, DISCOMFORT I have moderate pain or discomfort clothes without assistance. may use object for support, I have extreme pain or discomfort 3 such as cane walk frame or. wheelchair and may manage, ANXIETY I am not anxious or depressed 1 night bedpan or commode. emptying same in morning, DEPRESSION I am moderately anxious or depressed D Receives assistance in.
going to toilet room or in, I am extremely anxious or depressed 3 cleaning self or in arranging. clothes after elimination or in,use of night bedpan or. D Doesn t go to room termed,toilet for the elimination. TRANSFER I Moves in and out of bed as,well as in and out of chair. without assistance may be,using object for support such.
as cane or walk frame,D Moves in and out of bed,or chair with assistance. D Doesn t get out of bed,CONTINENCE I Controls urination and. bowel movement completely,D Has occasional accidents. D Needs supervision for,urine or bowel control,catheter is used or is. incontinent, We would like to know how good or bad your health is TODAY This scale is numbered from.
0 to 100 Mark an X on the scale to indicate how your health is TODAY 100 means the best. health you can imagine 0 means the worst health you can imagine. CRF B final version,GO SAFE Study,CRF B final version. GO SAFE Study,Mini Cog Clock Drawing,CRF B final version. GO SAFE Study,NUTRITIONAL RISK SCREENING, Weight in kg Height in cm BMI weight height x height. Mildly impaired nutritional status,Nutritional Status Score. 5 weight loss in 3 months or food intake below, 50 75 of normal requirement in preceding week Normal 0.
Moderately impaired nutritional status Mildly impaired 1. 5 weight loss in 2 months or BMI 18 5 20 5 Moderately impaired 2. impaired general condition or food intake 25 60, of normal requirement in preceding week Severely impaired 3. Severely impaired nutritional status Instructions circle appropriate score. 5 weight loss in 1 month 15 in 3 months,or BMI 18 5 impaired general condition or food. intake 0 25 of normal requirement in preceding,ECOG Performance Status. GO SAFE Study CRF B final version EQ 5D 3L VAS We would like to know how good or bad your health is TODAY This scale is numbered from 0 to 100 Mark an X on the scale to indicate how your health is TODAY 100 means the best

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