1.1
Age
1.2
Sex
1.5
What is your tobacco smoking status
1.7
Highest level of education
1.8
Current living arrangement
Height & Weight
1.10
Measuring method height
1.12
Height in cm
1.13
Measuring method weight
1.14
Weight in kg
1.15
Body Mass Index
2.1
For which parent, caregiver or teacher do you want to provide baseline information
2.2
Number of caregivers
Only shown if field 2.1 is equal to 2
2.3
Number of Teachers
Only shown if field 2.1 is equal to 4
Mother
Only shown if field 2.1 is equal to 0
2.6
Age
Only shown if field 2.1 is equal to 0
2.12
Highest level of education
Only shown if field 2.1 is equal to 0
Father
Only shown if field 2.1 is equal to 1
2.14
Age
Only shown if field 2.1 is equal to 1
2.15
Highest level of education
Only shown if field 2.1 is equal to 1
Caregiver 1
Only shown if field 2.2 is greater than or equal to 1
2.17
Age
Only shown if field 2.2 is greater than or equal to 1
2.18
Sex
Only shown if field 2.2 is greater than or equal to 1
2.19
Highest level of education
Only shown if field 2.2 is greater than or equal to 1
Caregiver 2
Only shown if field 2.2 is greater than or equal to 2
2.21
Age
Only shown if field 2.2 is greater than or equal to 2
2.22
Sex
Only shown if field 2.2 is greater than or equal to 2
2.23
Highest level of education
Only shown if field 2.2 is greater than or equal to 2
Caregiver 3
Only shown if field 2.2 is greater than or equal to 3
2.25
Age
Only shown if field 2.2 is greater than or equal to 3
2.26
Sex
Only shown if field 2.2 is greater than or equal to 3
2.27
Highest level of education
Only shown if field 2.2 is greater than or equal to 3
Teacher 1
Only shown if field 2.3 is greater than or equal to 1
2.29
Age
Only shown if field 2.3 is greater than or equal to 1
2.30
Sex
Only shown if field 2.3 is greater than or equal to 1
2.31
Highest level of education
Only shown if field 2.3 is greater than or equal to 1
Teacher 2
Only shown if field 2.3 is greater than or equal to 2
2.33
Age
Only shown if field 2.3 is greater than or equal to 2
2.34
Sex
Only shown if field 2.3 is greater than or equal to 2
2.35
Highest level of education
Only shown if field 2.3 is greater than or equal to 2
Teacher 3
Only shown if field 2.3 is greater than or equal to 3
2.37
Age
Only shown if field 2.3 is greater than or equal to 3
2.38
Sex
Only shown if field 2.3 is greater than or equal to 3
2.39
Highest level of education
Only shown if field 2.3 is greater than or equal to 3
Teacher 4
Only shown if field 2.3 is greater than or equal to 4
2.41
Age
Only shown if field 2.3 is greater than or equal to 4
2.42
Sex
Only shown if field 2.3 is greater than or equal to 4
2.43
Highest level of education
Only shown if field 2.3 is greater than or equal to 4
Teacher 5
Only shown if field 2.3 is greater than or equal to 5
2.45
Age
Only shown if field 2.3 is greater than or equal to 5
2.46
Sex
Only shown if field 2.3 is greater than or equal to 5
2.47
Highest level of education
Only shown if field 2.3 is greater than or equal to 5
Teacher 6
Only shown if field 2.3 is greater than or equal to 6
2.49
Age
Only shown if field 2.3 is greater than or equal to 6
2.50
Sex
Only shown if field 2.3 is greater than or equal to 6
2.51
Highest level of education
Only shown if field 2.3 is greater than or equal to 6
3.1
Age
3.2
Myocardial infarction
3.3
Congestive heart failure (CHF)
3.4
Peripheral vascular disease
3.5
CVA or TIA
3.6
Dementia
3.7
COPD
3.8
Connective tissue disease
3.9
Peptic ulcer disease
3.10
Liver disease
3.11
Diabetes mellitus
3.12
Hemiplegia
3.13
Moderate to severe chronic kidney disease
3.14
Solid tumor
3.15
Leukemia
3.16
Lymphoma
3.17
AIDS
3.18
CCI-Score
3.19
10-year survival rate
Under each heading, please tick the ONE box that best describes your health TODAY.
4.2
Mobility
4.3
Self-care
4.4
Usual activities (e.g. work, study, housework, family or leisure activities)
4.5
Pain / Discomfort
4.6
Anxiety/ Depression
4.7
We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100. 100 means the best health you can imagine. 0 means the worst health you can imagine. How would you rate your health
Under each heading, please tick the ONE box that best describes the patients health TODAY.
5.2
Mobility
5.3
Self-Care
5.4
Usual activities (e.g. work, study, housework, family or leisure activities)
5.5
Pain / Discomfort
5.6
Anxiety / Depression
5.7
We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100. 100 means the best health you can imagine. 0 means the worst health you can imagine. How would you rate your health
6.1
1. In general would you say your health is
2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
6.3
2a. Moderate activities, such as moving a table, pushing a vacuum clearner, bowling, or playing golf
6.4
2b. Climbing several flights of stairs
3. During the past week, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
6.6
3a. Accomplished less than you would like
6.7
3b. Were limited in the kind of work or other activites
4. During the past week, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
6.10
4a. Accomplished less than you would like
6.11
4b. Didn't do work or other activities as carefully as usual
6.12
5. During the past week, how much did pain interfere with your normal work (including both work outside the home and housework)?
6. These questions are about how you feel and how things have been with you during the past week. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past week -
6.14
6a. Have you felt calm and peaceful
6.15
6b. Did you have a lot of energy?
6.16
6c. Have you felt downhearted and blue?
6.17
7. During the past week, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
6.18
PF
6.19
RP
6.20
BP
6.21
GH
6.22
VT
6.23
SF
6.24
RE
6.25
MH
6.26
PF Z
6.27
RP Z
6.28
BP Z
6.29
GH Z
6.30
VT Z
6.31
SF Z
6.32
RE Z
6.33
MH Z
6.35
physical component score
6.36
Mental component score
6.37
physical component score
6.38
mental component score
7.1
1. In general, would you say your health is
7.2
2. Compared to one year ago, how would you rate your health in general now?
3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
7.4
3a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.
7.5
3b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
7.6
3c. Lifting or carrying groceries
7.7
3d. Climbing several flights of stairs
7.8
3e. Climbing one flight of stairs
7.9
3f. Bending, kneeling, or stooping
7.10
3g. Walking more than a mile
7.11
3h. Walking several blocks
7.12
3i. Walking one block
7.13
3j. Bathing or dressing yourself
4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
7.15
4a. Cut down the amount of time you spent on work or other activities
7.16
4b. Accomplished less than you would like
7.17
4c. Were limited in the kind of work or other activities
7.18
4d. Had difficulty performing the work or other activities (for example, it took extra effort)
5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
7.20
5a. Cut down the amount of time you spent on work or other activities Yes
7.21
5b. Accomplished less than you would like
7.22
5c. Didn't do work or other activities as carefully as usual
7.23
6. Emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
7.24
7. How much bodily pain have you had during the past 4 weeks?
7.25
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
9. These questions are about how you feel and how things have been with you during the last 4 weeks. For each question, please give the answer that comes closest to the way you have been feeling
7.27
9a. Did you feel full of life?
7.28
9b. Have you been a very nervous person?
7.29
9c. Have you felt so down in the dumps that nothing could cheer you up?
7.30
9d. Have you felt calm and peaceful?
7.31
9e. Did you have a lot of energy?
7.32
9f. Have you felt downhearted and blue?
7.33
9g. Did you feel worn out?
7.34
9h. Have you been a happy person?
7.35
9i. Did you feel tired?
7.36
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
11. How true or false is each of the following statements for you?
7.38
11a. I seem to get sick a little easier than other people
7.39
11b. I am as healthy as anybody I know
7.40
11c. I expect my health to get worse
7.41
11d. My health is excellent
7.42
PF
7.43
SF
7.44
RP
7.45
RE
7.46
MH
7.47
VT
7.48
BP
7.49
GH
7.50
HT
7.51
PF Z
7.52
SF Z
7.53
RP Z
7.54
RE Z
7.55
MH Z
7.56
VT Z
7.57
BP Z
7.58
GH Z
7.59
Praw
7.60
Mraw
7.61
Physical component score
7.62
Mental component score
8.1
Health status
8.2
Appetite
8.3
Pain
8.4
Fatigue
8.5
Fear of falling
9.1
Control over daily life
9.2
Personal cleanliness and comfort
9.3
Food and drink
9.4
Personal safety
9.5
Social participation and involvement
9.6
Occupation
9.7
Accommodation cleanliness and comfort
9.8
Dignity
9.9
Score
10.1
Are you basically satisfied with your life ?
10.2
Have you dropped many of your activities and interests?
10.3
Do you feel that your life is empty?
10.4
Do you often get bored?
10.5
Are you in good spirits most of the time?
10.6
Are you afraid that something bad is going to happen to you?
10.7
Do you feel happy most of the time ?
10.8
Do you often feel helpless?
10.9
Do you prefer to stay at home, rather than going out and doing new things?
10.10
Do you feel you have more problems with memory than most?
10.11
Do you think it is wonderful to be alive now?
10.12
Do you feel pretty worthless the way you are now ?
10.13
Do you feel full of energy ?
10.14
Do you feel that your situation is hopeless ?
10.15
Do you think that most people are better off than you are ?
10.16
GDSscore
Tick the box beside the reply that is closest to how you have been feeling in the past week. Don’t take too long over you replies: your immediate is best.
11.2
1. I feel tense or 'wound up'
11.3
2. I still enjoy the things I used to enjoy.
11.4
3. I get a sort of frightened feeling as if something awful is about to happen.
11.5
4. I can laugh and see the funny side of things
11.6
5. Worrying thoughts go through my mind.
11.7
6. I feel cheerful
11.8
7. I can sit at ease and feel relaxed
11.9
8. I feel as if I am slowed down.
11.10
9. I get a sort of frightened feeling like 'butterflies' in the stomach.
11.11
10. I have lost interest in my appearance.
11.12
11. I feel restless as I have to be on the move.
11.13
12. I look forward with enjoyment to things.
11.14
13. I get sudden feelings of panic.
11.15
14. I can enjoy a good book or radio or TV program.
11.16
HADS Anxiety score
11.17
HADS Depression score
12.1
1a. What is the year?
12.2
1b. What is the season?
12.3
1c. What is the date?
12.4
1d. What is the day of the week?
12.5
1e. What is the month?
12.6
2a. In which province are we now?
12.7
2b. In which town are we now?
12.8
2c. In which hospital are we now?
12.9
2d. In which department are we now?
12.10
2e. On which floor are we now?
12.11
3. I will name three objects. Would you repeat them after I've said all three? Remember them, because I ask you to mention them again in a few minutes. Apple, Key, Table (repeat max 5 times until patient knows, give points after the first time)
12.12
4. I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65, …), Stop after five answers
12.13
5. Earlier I told you the names of three things. Can you tell me what those were?
12.14
6. Show the patient a wristwatch and a pencil, and ask the patient to name them.
12.15
7. Repeat the phrase: ‘No ifs, ands, or buts.’
12.16
8. Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the patient a piece of blank paper)
12.17
9. Please read this and do what it says.” (Written instruction is “Close your eyes.”)
12.18
10. Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.)
12.19
11. Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and two must intersect.)
12.20
MMSE Score
13.1
1. Please imagine that this pre-drawn circle is a clock. I would like you to place the numbers in the correct positions then place the hands to indicate a time of ‘ten after eleven’
13.2
2. In the past year, how many times have you been admitted to a hospital?
13.3
3. In general, how would you describe your health?
13.5
4. With how many of the following activities do you require help? (meal preparation, shopping, transportation, telephone, housekeeping, laundry, managing money, taking medications)
13.6
5. When you need help, can you count on someone who is willing and able to meet your needs?
13.7
6. Do you use five or more different prescription medications on a regular basis?
13.8
7. At times, do you forget to take your prescription medications?
13.9
8. Have you recently lost weight such that your clothing has become looser?
13.10
9. Do you often feel sad or depressed?
13.11
10. Do you have a problem with losing control of urine when you don’t want to?
13.12
11. I would like you to sit in this chair with your back and arms resting. Then, when I say ‘GO’, please stand up and walk at a safe and comfortable pace to the mark on the floor (approximately 3 m away), return to the chair and sit down’
13.13
Culculation Edmonton-Frailty EN
13.14
Edmonton Frailty Scale Score group

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Sex
0: Female
1: Male
2: Other
Smokingstatus
1: Current every day smoker
2: Current some day smoker
3: Former smoker
4: Never smoker
Educationallevel
1: Primary education
2: Secondary education
3: Practical higher education
4: Theoretical higher education
Livingarrangement
1: Lives alone
2: With partner
3: With other family member
4: With a friend
5: With Paid help or in a care facility
Heightweightmethod
0: Self-reported
1: Measured
Caregivers
0: Mother
1: Father
2: Caregivers
4: Teachers
Age
0: <50
1: 50-59
2: 60-69
3: 70-79
4: ≥80
Myocardial_infarction
0: No
1: Yes
No (0) Yes (1)
0: No
1: Yes
Liver_disease
0: None
1: Mild
3: Moderate to severe
Diabetes_mellitus
0: None or diet-controlled
1: Uncomplicated
2: End-organ damage
No (0) Yes (2)
0: No
2: Yes
Solid_tumor
0: None
2: Localized
6: Metastatic
EQ5D5L_mobility
1: I have no problems in walking about
2: I have slight problems in walking about
3: I have moderate problems in walking about
4: I have severe problems in walking about
5: I am unable to walk about
EQ5D5L_selfcare
1: I have no problems washing or dressing myself
2: I have slight problems washing or dressing myself
3: I have moderate problems washing or dressing myself
4: I have severe problems washing or dressing myself
5: I am unable to wash or dress myself
EQ5D5L_usualactivity
1: I have no problems doing my usual activities
2: I have slight problems doing my usual activities
3: I have moderate problems doing my usual activities
4: I have severe problems doing my usual activities
5: I am unable to do my usual activities
EQ5D5L_paindiscomfort
1: I have no pain or discomfort
2: I have slight pain or discomfort
3: I have moderate pain or discomfort
4: I have severe pain or discomfort
5: I have extreme pain or discomfort
EQ5D5L_anxietydepression
1: I am not anxious or depressed
2: I am slightly anxious or depressed
3: I am moderately anxious or depressed
4: I am severely anxious or depressed
5: I am extremely anxious or depressed
EQ5D_mobility
1: I have no problems in walking about
2: I have some problems in walking about
3: I am confined to bed
EQ5D_selfcare
1: I have no problems with self-care
2: I have some problems washing or dressing myself
3: I am unable to wash or dress myself
EQ5D_usualactivities
1: I have no problems with performing my usual activities
2: I have some problems with performing my usual activities
3: I am unable to perform my usual activities
EQ5D_Paindiscomfort
1: I have no pain or discomfort
2: I have moderate pain or discomfort
3: I have extreme pain or discomfort
EQ5D_anxietydepression
1: I am not anxious or depressed
2: I am moderately anxious or depressed
3: I am extremely anxious or depressed
SF12_1
5: Excellent
4.4: Very good
3.4: Good
2: Fair
1: Poor
SF12_2
1: Yes, Limited a lot
2: Yes, Limited a little
3: No, Not limited at all
SF12_3
1: Always
2: Mostly
3: Sometimes
4: Rarely
5: Never
SF12_4
1: Always
2: Mostly
3: Sometimes
4: Rarely
5: Never
SF12_5
5: Never
4: Rarely
3: Sometimes
2: Mostly
1: Always
SF12_6a
5: Always
4: Mostly
3: Sometimes
2: Rarely
1: Never
SF12_6b
5: Always
4: Moslty
3: Sometimes
2: Rarely
1: Never
SF12_6c
1: Always
2: Mostly
3: Sometimes
4: Rarely
5: Never
SF12_7
1: Always
2: Mostly
3: Sometimes
4: Rarely
5: Never
SF36_1
5: Excellent
4: Very good
3: Good
2: Moderate
1: Poor
SF36_2
5: Much better than a year ago
4: Slightly better than a year ago
3: About the same as a year ago
2: Slightly worse than a year ago
1: Much worse than a year ago
SF36_3
1: Yes, Limited a lot
2: Yes, Limited a Little
3: No, Not Limited at all
SF36_4
1: All of the time
2: Most of the time
3: Some of the time
4: A little of the time
5: None of the time
SF36_5
1: All of the time
2: Most of the time
3: Some of the time
4: A little of the time
5: None of the time
SF36_6
5: Not at all
4: Slightly
3: Moderately
2: Severe
1: Very Severe
SF36_7
6: None
5: Very mild
4: Mild
3: Moderate
2: Severe
1: Very severe
SF36_8
5: Not at all
4: A little bit
3: Moderately
2: Quite a bit
1: Extremely
SF36_9contra
5: All of the time
4: Most of the time
3: Some of the time
2: A little bit of the time
1: None of the Time
SF36_9
1: All of the time
2: Most of the time
3: Some of the time
4: A little of the time
5: None of the time
SF36_10
1: All of the time
2: Most of the time
3: Some of the time
4: A little bit of the time
5: None of the time
SF36_11
1: Definitely true
2: Mostly true
3: Don't know
4: Mostly false
5: Definitely false
SF36_11contra
5: Definitely true
4: Mostly true
3: Don't know
2: Mostly false
1: Definitely false
ASCOT1
1.000: I have as much control over my daily life as I want
0.919: I have adequate control over my daily life
0.541: I have some control over my daily life but not enough
0.000: I have no control over my daily life
ASCOT2
0.911: I feel clean and am able to present myself the way I like
0.789: I feel adequately clean and presentable
0.265: I feel less than adequately clean or presentable
0.195: I don’t feel at all clean or presentable
ASCOT3
0.879: I get all the food and drink I like when I want
0.775: I get adequate food and drink at OK times
0.294: I don’t always get adequate or timely food and drink
0.184: I don’t always get adequate or timely food and drink, and I think there is a risk to my health
ASCOT4
0.880: I feel as safe as I want
0.452: Generally I feel adequately safe, but not as safe as I would like
0.298: I feel less than adequately safe
0.114: I don’t feel at all safe
ASCOT5
0.873: I have as much social contact as I want with people I like
0.748: I have adequate social contact with people
0.497: I have some social contact with people, but not enough
0.241: I have little social contact with people and feel socially isolated
ASCOT6
0.962: I’m able to spend my time as I want, doing things I value or enjoy
0.927: I’m able do enough of the things I value or enjoy with my time
0.567: I do some of the things I value or enjoy with my time but not enough
0.170: I don’t do anything I value or enjoy with my time
ASCOT7
0.863: My home is as clean and comfortable as I want
0.780: My home is adequately clean and comfortable
0.374: My home is less than adequately clean or comfortable
0.288: My home is not at all clean or comfortable
ASCOT8
0.847: The way I'm helped and treated makes me think and feel better about myself
0.637: The way I’m helped and treated does not affect the way I think or feel about myself
0.295: The way I’m helped and treated sometimes undermines the way I think and feel about myself
0.263: The way I’m helped and treated completely undermines the way I think and feel about myself
No (1) Yes (0)
1: No
0: Yes
HADS_1
3: Most of the time
2: A lot of the time
1: From time to time, occasionally
0: Not at all
HADS_2
0: Definitely as much
1: Not quite so much
2: Only a little
3: Hardly at all
HADS_3
3: Very definitely and quite badly
2: Yes, but not too badly
1: A little, but it doesn't worry me
0: Not at all
HADS_4
0: As much as I always could
1: Not quite so much now
2: Definitely not so much now
3: Not at all
HADS_5
3: A great deal of the time
2: A lot of the time
1: From time to time, but not too often
0: Only occasionally
HADS_6
3: Not at all
2: Not often
1: Sometimes
0: Most of the time
HADS_7
0: Definitely
1: Usually
2: Not Often
3: Not at all
HADS_8
3: Nearly all the time
2: Very often
1: Sometimes
0: Not at all
HADS_9
0: Not at all
1: Occasionally
2: Quite Often
3: Very Often
HADS_10
3: Definitely
2: I don't take as much care as I should
1: I may not take quite as much care
0: I take just as much care as ever
HADS_11
3: Very much indeed
2: Quite a lot
1: Not very much
0: Not at all
HADS_12
0: As much as I ever did
1: Rather less than I used to
2: Definitely less than I used to
3: Hardly at all
HADS_13
3: Very often indeed
2: Quite often
1: Not very often
0: Not at all
HADS_14
0: Often
1: Sometimes
2: Not often
3: Very seldom
Correct/Wrong
1: Correct
0: Wrong
threecorrect
3: 3 correct
2: 2 correct
1: 1 correct
0: 0 correct
Fivecorrect
5: 5 correct
4: 4 correct
3: 3 correct
2: 2 correct
1: 1 correct
0: 0 correct
twocorrect
2: 2 correct
1: 1 correct
0: 0 correct
Cognition
0: No errors
1: Minor spacing errors
2: Other errors
General_Health_Status1
0: 0
1: 1-2
2: 3 or more
General_Health_Status2
0: Exellent/Very good/Good
1: Fair
2: Poor
Functional_Independence
0: 0-1
1: 2-4
2: 5-8
Social_Support
0: Always
1: Sometimes
2: Never
Functional_Performance
0: 0-10 s
1: 11-20 s
2: >20 s/patient unwilling/requires assistance