Name:  ID: 1044172
Gender:

Male            Age:  80+

 Date: 5/15/2003 2:41:57 PM

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Web Quiz v3.0
Last reviewed 11/2002

© 1997-2003
FNX Corporation and
Trustees of
Dartmouth College.

All Rights Reserved.

 

Thank you for completing the Improve Your Medical Care questionnaire.

Taking this letter to your doctor will help to improve the medical care you receive.

From reading your responses to this questionnaire, we learned that you feel your overall health to be very good.

In reporting your quality of life, you indicated things have been going pretty good.

You are having difficulty:

  • travelling alone
  • shopping
  • preparing your own meals
  • doing housework
  • handling your own money
  • buying essentials
  • driving

You manage your 'aging' problems by the use of:

  • braces(s) or prosthesis
  • a hearing aid

In the last four weeks, you have seen:

  • Your own or another doctor

When you completed the Improve Your Medical Carequestionnaire, you may have had the following risks to your health:

  • You are a smoker
  • You drink more than 6 alcoholic drinks per week
  • You do not have any money for essentials
  • You have difficulty driving
  • You are unclear about advance directive
  • You have not written down your advance directive
  • You have not had a Pneumovax
  • You have not had a Flu Shot
  • You have not had a Tetanus Shot
  • You have not had a TB test
  • You have not been told about Home Hazards
  • You have not been given a method to keep track of your medications
  • You are spending $25 or more each month on medication


Based on your responses to the HowsYourHealth.com questionnaire, we recommend that you read the following sections of the Improve Your Health or How's Your Health booklet:

 
 
Name:  ID: 1044172
Gender:

Male            Age:  80+

 Date: 5/15/2003 2:41:57 PM
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ACTION FORM
ASSETS
FUNCTION HABITS KNOWLEDGE PREVENTION

BMI: 15.4 		Overall Health - Very Good
 		      
NEEDS
CLINICIAN ASSESSMENTS
REFERRALS/ACTIONS		 SUGGESTED
READINGS/EDUCATION
FUNCTION
Unable to travel
Unable to shop
Unable to prepare meals
Unable to do housework
Unable to handle money

SYMPTOMS/BOTHERS

DEVICES USED
Brace/prosthesis
Hearing aid

HABITS
Smoker
More than 6 drinks

PREVENTION
No Pneumovax
No flu shot
No tetanus shot
No info on hazards
No info on medications
No written advanced directive
Difficulty driving
Lacks money for essentials

OTHER		  
RISK-RELATED
CONSIDERATIONS
More than 3 meds, or f/p health, or more than 3 activity limits

Very good or excellent health and no other risks



Italics = Clinician Unaware

 
Advanced Directive - yes, on file, buf not on file
Learning Preferences - , language assistance desired

Provider:____________________ Date:__________ Signature:____________________


© 1997-2000FNX Corporation and Trustees of Dartmouth College. All Rights Reserved.

 
Name:  ID: 1044172
Gender:

Male            Age:  80+

 Date: 5/15/2003 2:41:57 PM
Condition Management Form
Persons who have conditions or diseases like yours can GREATLY improve their health and their medical care by three simple steps.
  1. Learning about how the care you have been getting might be made better.
  2. Learning if there things you should be aware of.
  3. Keeping track of your condition by writing down a few measures from week to week.
You have the following disease(s) or condition(s):
  • High Blood Pressure
 
High blood pressure issues:
  • You have not received good education about:
    • What to do if you miss a dose of your medicine
    • The effect of weight and salt on our blood pressure
    • The problems blood medications might cause you
 Things you should be aware of:
  • your blood pressure should be no higher than 150/90, even for those 70 years of age or older
  • avoid high salt.
These are general hints for management. Some are in medical language.
You may want to talk about what is written on this sheet with a doctor or nurse when you show them your "Action Form". On the next page you will find a way to keep track of your condition by writing down a few measures from week to week.
 
Name:  ID: 1044172
Gender:

Male            Age:  80+

 Date: 5/15/2003 2:41:57 PM

What You Check
Your Name _______________________
Date
5/15/2003 2:41:57 PM   ________    ________    ________    ________

Weight
100-120        ________    ________    ________    ________

Blood Pressure
100-120/60-70    ________    ________    ________    ________

Cholesterol
101-130         ________    ________    ________    ________

________    ________    ________    ________    ________


What You Notice*

 

________    ________    ________    ________    ________
*List what bothers you or what you have been told to watch here.
Write 1 for great, 2 for "ok", 3 for not so good, 4 for bad, 5 for horrible.