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Geriatric Assessment Tool
Stall Quality of Life Scale
Client Name
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Assessment Date
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________________________________________ |
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How do your rate your overall quality of life? What could make it better?
On a scale of 1 to 10, where 1 is "terrible" and 10 is "great!",
how would you rate your life right now (circle one)?
What is one thing you wish or think could be better to make your quality of life increase? |
| 1. |
What is another thing you wish or think could be better to make your quality of life
increase? |
| 2. |
And a third thing you wish or think could be better to make your quality of life increase? |
| 3. |
Comments:
Discuss with your primary care doctor ways you can improve your overall quality of life
to one more than what you rated it.
For example, if you said “5”, try to aim for a “6”. Even if you said your were a “10”, try to
work toward an “11”.
Or if you were “‐1”, try to figure out how to get to a “0”.
Assessed By
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Signature
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________________________________ |
________________________________ |
References
Copyright © Stall Geriatrics LLC - What Should You Expect At Your Age? A Lot! ™ |
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Stall Geriatrics LLC, 350 Greenhaven Terrace, Tonawanda, NY 14150 W 716-213-4345 F 888-387-1238 E-mail drstall@stallgeriatrics.com
Copyright © Stall Geriatrics LLC - What Should You Expect At Your Age? A Lot! ™
Senior-Friendly, Senior-Smart Organizations and Communities • Expert Witness and Medical Case Review • Information for Older Adults, Baby Boomers, Caregivers and Health Professionals • Long Term Care System Improvement, Liability Reduction and Medical Staff Issues •
Technology-Assisted Geriatric Care
"The place you are called to is where
your deep gladness meets the world's great hunger"
from Frederick Buechner
Last update 4/20/11
with Grandma Elsie |
with Grandpa Al |
with Grandma Goldie |
 with Grandpa Julius |
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