normally enjoy? Over the Past Week: Always Most of Sometimes Not at all Cannot Intervention the time Assess offered or provided? Q6: Do you 0 1 2 3 4 No 0 think s/he felt Yes 1 at peace? Q7: Has s/he 0 1 2 3 4 No 0 been able to Yes 1 interact positively with others (e.g. staff, family, residents)? Q7b: Can s/he 0 1 2 3 4 No 0 activities Yes 1 appropriate for his/her level of interests and abilities? Q8: Has 0 1 2 3 4 No 0 his/her family Yes 1 had as much information as wanted? Over the Past Week: Problems Problems Problems Problems Problems Cannot Intervention addressed/ mostly partly hardly not Assess offered or no problems addressed addressed addressed addressed provided? Q9: Have all 0 1 2 3 4 No 0 practical Yes 1 problems been addressed? (e.g. hearing aids, foot care, glasses, diet) Health Care Living Organ None Cannot Intervention Proxy Will Donation of Assess offered or Oral provided?
normally enjoy? Over the Past Week: Always Most of the time Sometimes Not at all Cannot Assess Intervention offered or provided? Q6: Do you think s/he felt at peace? 0 1 2 3 4 No 0 Yes 1 Q7: Has s/he been able to interact positively with others (e.g. staff, family, residents)? 0 1 2 3 4 No 0 Yes 1 Q7b: Can s/he activities appropriate for his/her level of interests and abilities? 0 1 2 3 4 No 0 Yes 1 Q8: Has his/her family had as much information as wanted? 0 1 2 3 4 No 0 Yes 1 Over the Past Week: Problems addressed/ no problems Problems mostly addressed Problems partly addressed Problems hardly addressed Problems not addressed Cannot Assess Intervention offered or provided? Q9: Have all practical problems been addressed? (e.g. hearing aids, foot care, glasses, diet) 0 1 2 3 4 No 0 Yes 1 Health Care Proxy Living Will Organ Donation of Oral None Cannot Assess Intervention offered or provided?
IPOS-DEM-03162017-Printable.docx