No. | Question | Scoring | |||||||
Response | Score | Response | Score | Response | Score | Response | Score | ||
1 | Do you need help to do the following? Bathing Bed mobility Medication management Transferring Ambulating Eating Toileting Dressing Personal hygiene | Zero to two selected | Zero | Three or more selected | Two | ||||
2 | Do you need help turning and repositioning? | No | Zero | Yes | Two | ||||
3 | Who helps you with daily activities? | No one | One | Family/friend/other/paid help | Zero | ||||
4 | During the last six months, have you had a fall that caused injuries? | No | Zero | Yes | Two | ||||
5 | Have you had a hospitalization, or been admitted to a nursing facility, or both, in the past six months? | No | Zero | Yes | Two | ||||
6 | Have you received rehabilitation in the past six months? | No | Zero | Yes | Two | ||||
7 | Have you been treated in an emergency room, called 911 in the past six months, or both? | No | Zero | Yes, one to two times | One | Yes, three or more times | Two | ||
8 | Do you live alone? | No | Zero | Yes | Two | ||||
If yes, do you feel safe living alone? | No | One | Yes | Zero | |||||
9 | Do you plan on moving to other housing in the near future? | No | Zero | Yes | Two | ||||
10 | Do you or your family have concerns about your memory, thinking, ability to make decisions, or remembering to pay your bills? | No, not concerned | Zero | Yes, somewhat concerned | One | Yes, very concerned | Two | ||
11 | Are you content with your social life? | No | Two | Somewhat | One | Yes | Zero | ||
12 | Over the last two weeks, have you been bothered by, or have little interest in doing things? | Not at all | Zero | Several days | One | More than half the days | Two | Nearly every day | Three |
13 | Over the last two weeks, have you been bothered by feeling down, depressed, or hopeless? | Not at all | Zero | Several days | One | More than half the days | Two | Nearly every day | Three |
Risk level | Point totals |
No risk | 0 |
Low risk | 1- 8 |
Moderate risk | 9-16 |
High risk | 17 and up |