Geriatric Mental Health Assessment Form

• Patient Name

• Hospital / Ward

• Treating Doctor

• Conducted on

  Date

• Conducted by

Mini-Cognitive Assessment

• Follow the steps below and provide answers to interpretation items.
  
  Step 1: Ask the patient to repeat three unrelated words, such as "ball," "dog," and window."
  Step 2: Ask the patient to draw a simple clock set to 10 minutes after eleven o'clock (11:10). A correct reposnse is drawing of a circle with the numbers placed in approxiamtely the correct positions, with the hands pointing to the 11 and 2.
  Step 3: Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.

• Number of items correctly recalled

  0

  1

  2

  3

• Clock drawing test result

  Normal

  Abnormal

• Interpretation of screen for dementia

  Negative

  Positive

Geriatric Depression Scale

• Are you basically satisfied with your life?

  Yes

  No

• Have you dropped many of your activities and interests?

  Yes

  No

• Do you feel that your life is empty?

  Yes

  No

• Do you often get bored?

  Yes

  No

• Are you in good spirits most of the time?

  Yes

  No

• Are you afraid that something bad is going to happen to you?

  Yes

  No

• Do you feel happy most of the time?

  Yes

  No

• Do you often feel helpless?

  Yes

  No

• Do you prefer to stay at home, rather than going out and doing new things?

  Yes

  No

• Do you feel you have more problems with memory than most?

  Yes

  No

• Do you think it is wonderful to be alive now?

  Yes

  No

• Do you feel pretty worthless the way you are now?

  Yes

  No

• Do you feel full of energy?

  Yes

  No

• Do you feel that your situation is hopeless?

  Yes

  No

• Do you think that most people are better off than you are?

  Yes

  No

Completion

• Name & Signature of Assigned Physician

  Sign