Questions Patients

Score
1. Are you basically satisfied with your life? Yes No 0
2. Have you dropped many of your activities or Yes No 0
interests?
3. Do you feel that your life is empty? Yes No 0
4. Do you often get bored? Yes No 0
5. Are you in good spirits most of the time? Yes No 0
6. Are you afraid that something bad is going to Yes No 0
happen to you?
7. Do you feel happy most of the time? Yes No 1
8. Do you feel helpless? Yes No 0
9. Do you prefer to stay at home, rather than go out Yes No 1
and do things?
10. Do you feel that you have more problems with Yes No 0
memory than most?
11. Do you think it is wonderful to be alive now? Yes No 0
12. Do you feel pretty worthless the way you are now? Yes No 1
13. Do you feel full of energy? Yes No 1
14. Do you feel that your situation is hopeless? Yes No 0
15. Do you think that most people are better off then Yes No 0
you are?
Total Score 4
Answers in bold indicate depression
Score: 5-9 Suggestion depression
Score 10 Depression
 Criteria Score
1. Unintentional weight loss ( >4,5 Kg in the last year ) 0
2. Low Physical Activities 1
3. Exhaustion ( self-report ) 0
4. Low Grip Strength 0
5. Slow Walking Time 0
Total Score 1
0: Normal
1-2: pre-frailty
3: Frailty

Screening Score
A. Has food intake declined over the past 3 0 = severe decrease in food intake 2
months due to loss of appetite, digestive 1 = moderate decrease in food
problems, chewing or swallowing intake
difficulties? 2 = no decrease in food intake
B. Weight loss during the last 3 months 0 = weight loss greater than 3 kg 3
(6.6 lbs)
1 = does not know
2 = weight loss between 1 and 3 kg
(2.2 and 6.6 lbs)
3 = no weight loss
C. Mobility 0 = bed or chair bound 2
1 = able to get out of bed / chair but
does not go out
2 = goes out
D. Has suffered psychological stress or acute 0 = yes 2
disease in the past 3 months? 2 = no
E. Neuropsychological problems 0 = severe dementia or depression 2
1 = mild dementia
2 = no psychological problems
F. Body Mass Index (BMI) (weight in kg) / 0 = BMI less than 19 3
(height in m) 2 1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
Total Score: 14
12-14 points: Normal nutritional status
8-11 points: At risk of malnutrition
0-7 points: Malnourished

Leg
Menit TD HR RR Watt/KP RPE BSDI Fatique Sat O2 Catatan
0 114/68 89 18 1,5 7 0,5 0,5 98
1 120/70 100 22 1,5 7 1 1 98
2 130/80 105 1,5 9 1 1 98
3 155/80 116 2 11 3 3 98
4 180/80 117 2 13 4 4 97
5
6 Latihan dihentikan pada menit ke 4 dengan 2 KP karena pasien merasa sesak
7
8
9 QSE : 14 Kg
10 HSE : 8 Kg
11
12
13
14
15
 Shoulder Pain and Disability Index (SPADI)

Pain scale
How severe is your pain?
Circle the number that best describes your pain where: 0 = no pain and 10 = the worst
pain imaginable.

At its worst? 0 1 2 3 4 5 6 7 8 9 10
When lying on the involved side? 0 1 2 3 4 5 6 7 8 9 10
Reaching for something on a high shelf? 0 1 2 3 4 5 6 7 8 9 10
Touching the back of your neck? 0 1 2 3 4 5 6 7 8 9 10
Pushing with the involved arm? 0 1 2 3 4 5 6 7 8 9 10

Disability scale
How much difficulty do you have?
Circle the number that best describes your experience where: 0 = no difficulty and 10 = so
difficult it requires help.

Washing your hair? 0 1 2 3 4 5 6 7 8 9 10

Washing your back? 0 1 2 3 4 5 6 7 8 9 10
Putting on an undershirt or jumper? 0 1 2 3 4 5 6 7 8 9 10
Putting on a shirt that buttons down the
front? 0 1 2 3 4 5 6 7 8 9 10
Putting on your pants? 0 1 2 3 4 5 6 7 8 9 10
Placing an object on a high shelf? 0 1 2 3 4 5 6 7 8 9 10
Carrying a heavy object of 10 pounds (4.5
kilograms) 0 1 2 3 4 5 6 7 8 9 10
Removing something from your back
pocket? 0 1 2 3 4 5 6 7 8 9 10

Higher score on the SPADI indicate worse pain

and disability
Assessment Tools Patients Conclusion
Score
Cognitive Function MMSE 30 No cognitive
impairment
Activity Daily Living The Barthel Index 20 Independent
Instrumental ADL Lawtons Score 9 Independent
Fall Risk Fall Risk Scale 4 High Risk of Fall
Exhaustion Fatigue Severity Scale 22 No fatigue
Knee Function WOMAC 11%
Shoulder pain and SPADI 16%
disability
Emotion Geriatric Depression Scale 4 No depression
Nutrition Mini Nutritional Assessment 14 Normal
Frailty in Elderly Fried Frailty Assessment 1 Pre- frailty