Welcome to the Centre for Aging and Wellness at Florida Hospital!

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133 Benmore Dr. Winter Park, FL 32789 PH: 407-599-6060 FAX: 407-646-7747 Welcome to the Centre for Aging and Wellness at Florida Hospital! We are pleased you have chosen us as part of your health care team. Enclosed are several forms, completion of which will enable us to better serve you at your appointment. What to bring to your appointment: ü Enclosed forms, filled out before your arrival. ü ALL current medications in their original bottles. This includes prescription and over-the-counter medicines, vitamins and herbal remedies. ü Pertinent records from other physicians. This includes recent lab work results, diagnostic studies (radiology and cardiology studies, for example), and a list of medical diagnoses. ü Family member(s), friend or caregiver. It is often helpful to have another person you trust present at your appointment. We offer two kinds of appointments. Your scheduled appointment is indicated below: Geriatric Team Assessment: You and your family member(s) and/or caregiver will meet with our team, including a board-certified geriatrician, a geriatric fellow, a family medicine resident, a social worker, a chaplain and a pharmacist. We apply an interdisciplinary approach to assessing the components of senior well-being, including memory, mobility, continence, vision, hearing, mood, medication and participation in family and community life. We may make recommendations for you, your family and your primary care physician to consider. A follow-up visit may be scheduled to review diagnostic studies and refine your care plan. Geriatric Physician Appointment: You and perhaps a family member and/or caregiver will meet with a board-certified geriatrician or a geriatric fellow (a medical doctor completing additional training in geriatrics). This can serve as a geriatric consult to augment care from your primary care physician, or you may choose to use our geriatrician or geriatric fellow as your primary doctor. Questions? Call us at 407-599-6060. We look forward to participating in your care!

Senior Assessment Clinical Summary Name: Date: MEDICAL HISTORY: Medication Allergies: Chronic medical problems: High blood pressure Heart disease: Lung disease: Diabetes Others: Last time you were hospitalized or in the ER and why: Past surgeries: HEALTH MAINTENANCE: ITEM DATE RESULT Women: Pap smear Mammogram Dexa (bone density) Men: Prostate check Both: Tetanus shot Pneumonia vaccine Flu shot Shingles vaccine Cholesterol check Colon cancer check

SOCIAL HISTORY: Who lives with you? Has anyone in your household moved from or visited a developing country in the past few years? Who would help you if you became ill or in an emergency? Do you feel unsafe in your current living situation? How do you get transportation? What is/was your occupation? What was the highest level of education you completed? How does your religion/faith affect your healthcare decisions? How do you pay for medical care? Have you ever had difficulty paying for the medications or medical care you need? Do you use tobacco in any form and how much? Do you use alcohol? How often? Do you use any illegal drugs? Do you have an advance directive? No, I would like information about my options Yes, I have a: Living Will Healthcare surrogate/ Durable Power of Attorney for Health Care Have you fallen all the way to the ground in the past 12 months? Yes No Do you often feel sad or blue? Yes No In the past year, have you ever lost your urine and gotten wet? Yes No Have you lost urine on at least 6 separate days? Yes No Because of your eyesight, do you have trouble driving, watching television, reading, or doing any of your daily activities? Yes No Does a hearing problem cause you difficulty listening to the TV or radio or hearing others speak? Yes No

FAMILY HISTORY: Does any blood relative of yours have: Dementia Cancer- What type? Heart disease Stroke Depression Diabetes REVIEW OF SYSTEMS: Please check if any of the following symptoms have troubled you recently: General fevers or sweats undesired weight loss falling Eyes vision worsening double vision Ears, Nose, Throat hearing loss difficulty swallowing Cardiovascular chest pain chest heaviness Respiratory short of breath coughing Gastrointestinal blood in stool diarrhea constipation Genitourinary blood in urine losing urine or wetting Sexual sex life could be better Musculoskeletal joint swelling muscle weakness Skin black moles changing moles Neurological seizures falling Psychiatric lack of pleasure and fun thoughts of suicide Endocrine hot flashes can t tolerate cold temperatures Hematology bruising easily bleeding frequently Allergy wheezing nasal congestion

Nutrition Screening Questionnaire Read the statements below. Circle the number in the YES column for those that apply to you or someone you know. YES I have and illness or condition that made me change the kind or 2 amount of food I eat. I eat fewer than two meals per day. 3 I eat few fruits and vegetables, or milk products. 2 I have three or more drinks of beer, liquor, or wine almost every 2 day. I have tooth or mouth problems that make it hard for me to eat. 2 I don t always have enough money to buy the food I need. 4 I eat alone most of the time. 1 I take three or more different prescribed or over-the-counter drugs 1 per day. Without wanting to, I have lost or gained 10 pounds in the past six 2 months. I am not always physically able to shop, cook, or feed myself. 2 Total:

The Zarit Caregiver Assessment Instructions for caregiver: The questions above reflect how persons sometimes feel when they are taking care of another person. After each statement, circle the word that best describes how often you feel that way. There are no right or wrong answers. Circle the response that best describes how you feel. 1. Do you feel that your relative asks for more help than he/she needs? 2. Do you feel that because of the time you spend with your relative that you don't have enough time for yourself? 3. Do you feel stressed between caring for your relative and trying to meet other responsibilities for your family or work? 4. Do you feel embarrassed over your relative's behavior? 5. Do you feel angry when you are around your 6. Do you feel that your relative currently affects your relationships with other family members or friends in a negative way? 7. Are you afraid what the future holds for your 8. Do you feel your relative is dependent on you? 9. Do you feel strained when you are around your 10. Do you feel your health has suffered because of your involvement with your 11. Do you feel that you don't have as much privacy as you would like because of your 12. Do you feel that your social life has suffered because you are caring for your 13. Do you feel uncomfortable about having friends over because of your Never Rarely Sometimes Quite frequently Nearly always

14. Do you feel that your relative seems to expect you to take care of him/her as if you were the only one he/she could depend on? 15. Do you feel that you don't have enough money to take care of your relative in addition to the rest of your expenses? 16. Do you feel that you will be unable to take care of your relative much longer? 17. Do you feel you have lost control of your life since your relative's illness? 18. Do you wish you could leave the care of your relative to someone else? 19. Do you feel uncertain about what to do about your 20. Do you feel you should be doing more for your 21. Do you feel you could do a better job in caring for your 22. Overall, how burdened do you feel in caring for your Total:

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