The initial four tool kits (Memory Loss, Urinary Incontinence, Depression, and Falls) were developed for the Practicing Physician Education in Geriatrics project supported by a grant from the John A. Hartford Foundation through the American Geriatrics Society. The MIAH is providing continued support for the ongoing development of new tool kits. The tool kits are intended to help physicians
better understand the common 'Geriatric Syndromes' and contain educational materials, suggested guidelines, forms and tools
for evaluation, diagnosis and treatment.
The initial visit form helps in efficiently capturing relevant information that is important for quality and
Use the interactive form below to see detailed section descriptions of the intital visit form:
1. Roll your mouse over the white sections in the form.
2. The area will highlights to blue indicating that the section is active.
3. Click the active section (highlighted in blue) to view a detailed description.
Family Report: Behavior: Gathers scaled information on function.
This is a self-report version of a survey research tool, the Functional Assessment Questionnaire, developed by Pfeffer. It is completed by a close personal contact (spouse, family, friend) who rates ability in the listed areas. Validation studies on the original instrument used a cut-off score of 5 when used as a dementia screen. The higher the score, the more functionally impaired the patient.
Story of the Memory Problem: Practitioner records from Family Report and interview.
The story of the memory problem is the single most important tool for understanding the cause of memory loss. The patient generally cannot report the story. Family tend to be most aware of dramatic events, and often fail to report gradual functional loss without prompting. Ask them to go back to the very first time they thought something might be wrong, and work forward. Alzheimerís disease usually produces a slow, gradual decline over years. Vascular dementia is characteristically "stepwise", that is, spells or episodes of sudden change (as in stroke) with improvement between.
Review of Systems: Review of systems for problems relevant to dementia diagnosis or treatment. Collects information related to "rule outs" in dementia diagnosis.
Current Medical History: Active medical problems.
Former medical/surgical history: Remote events, looking for problems relevant to cognitive loss.
Psychiatric history: Depression critical exclusion, can be lifelong.
Medications: List developed prior to visit. Adverse drug effects are common causes of treatable confusion. Benzodiazepines, anticholinergics particularly troublesome.
Positives: Space to record additional information on positive findings from Past Med Hx, ROS, Fam Hx.etc.
Past Medical History: Collects information on specific conditions with implications for memory loss diagnosis.
Many specific conditions are relevant to dementia differential diagnosis. Vascular events and risks relate
to vascular dementia diagnosis. Organ failure (liver, kidney, heart, lung, liver) can cause confusion.
Remote alcoholism and head injury can cause cognitive loss. Intracranial hemorrhage and meningitis are risks
for normal pressure hydrocephalus. Sensory deprivation (severe losses of vision and hearing) can mimic dementia.
Family History: Identifies familial dementia risk. Alzheimerís risk is 50% higher in those with an affected
first degree relative. Vascular and Parkinsonís disease risks are also familial.
Education: Used in norms of MMSE
Employment: Information relevant to exposures
Health Habits: Smoking is a vascular risk; excessive alcohol use a common source of treatable confusion.