Area | Questions | Response scale and trigger |
---|---|---|
Social Environment | Social support | Â |
 | Living circumstances Carer for someone else at home Someone to call on for help Frequency of social contacts | Live alone or is carer and nobody to call on for help or rarely sees relatives/friends |
 | Self care |  |
 | Wash all over | Unable and no help |
 | Get dressed | Unable and no help |
 | Cut toe nails | Unable and no help |
 | Cook hot meal | Unable and no help |
 | Do light housework or simple repairs | Unable and no help |
 | Financial problems |  |
 | Difficulty keeping home warm | Often or always |
 | Problems in making ends meet | Always |
Sensory impairment | Difficulty hearing | A lot |
 | Difficulty seeing newsprint | A lot |
Mental condition | Feeling sad, depressed or miserable | Often or always |
 | Problems with everyday memory | Always |
 | Difficulty managing finances | Always |
 | Problems remembering medication | Often or always |
Physical condition | Vomited blood | Yes1 |
 | Coughed up blood | Yes1 |
 | Severe shortness of breath sitting | Yes |
 | Severe swollen legs | Yes |
 | Unexpected weight loss | Yes1 |
 | Falls in last six months | > 41 |
Incontinence | Urinary | Once a week or more often |
 | Faecal | Once a week or more often |
Use of medicines | Number of prescribed medicines | > 7 |
Mobility | Walk 50 yards | Unable and no help |
 | Go up and down stairs and steps | Unable and no help |
 | Do shopping | Unable and no help |
Lifestyle (not part of GP contract) | Use of alcohol in previous week Current smoker (amount daily) Physical activity | Not included as trigger |
For nurse/lay only | Â | Any other condition/problem warranting a detailed assessment |