• Age (yrs):
• Gender:

  Male Female
• Height:

   

  Units:

  Inches cm
• Weight:

   

  Units:

  pounds kg
• Computed BMI:
• Serum Albumin:

   

   

  Not Done

Gait Speed Assessment and Calf Circumference

• Walk Time (# of seconds in 15 feet) (avg 2 trials)

   

  Assistive device for walking?

   

  Yes No

  If the walk was not done, please indicate reason:

   

  Unable to walk, even with support Other Reason n/a

• Calf Circumference (cm):

   

   

   

  Not Done

Activities of Daily Living and Cognition

• How much help does the patient need with the following activities?

   

  Bathing:

  No Help Some Help Full Help
  Dressing:

  No Help Some Help Full Help
  Toileting:

  No Help Some Help Full Help
  Transferring:

  No Help Some Help Full Help
  Feeding:

  No Help Some Help Full Help

  Does the patient have cognitive or neuropsychiatric impairment?

   

  No problems Mild Cognitive Impairment Moderate or Severe Cognitive Impairment n/a

Interviewer Administered Questions

• "Has your walking and movements slowed down recently?"

   

  No Slowing Some Slowing Severe Slowing n/a

• "How often have you felt that everything you did was an effort in the last week?"

   

  Rarely or none of the time
  (≤1 day) Some or little of the time
  (1-2 days) Moderate amount of time
  (3-4 days) Most of the time n/a

• "How often did you feel you could not get going in the last week?"

   

  Rarely or none of the time
  (≤1 day) Some or little of the time
  (1-2 days) Moderate amount of time
  (3-4 days) Most of the time n/a

• "During the past year, have you unintentionally lost 10 or more pounds?"

   

  Yes No

• "How often do you engage in activities which require a low or moderate level of energy such as gardening, cleaning the car, or going for a walk?"

   

  More than once per week Once per week Monthly or less n/a