Screening tool Patient Details Patient Name: Patient ID: No results Quiz 🎯 Topic A. Demographic Characteristics A1. Gender Male Female Non-Binary 🎯Topic A. Demographic Characteristics A2. Education level Illiterate (less than 3 years of education) Primary school (3-6 years) Secondary school (7-12 years) Tertiary education (>12 years) 🎯Topic A. Demographic Characteristics A3. Income level No/Low Moderate High Not able to assess 🎯Topic A. Demographic Characteristics A4. Age 70 or less 71 and above Not able to assess 🎯Topic A. Demographic Characteristics A5. Area of residence Rural (Low population density, natural environment, limited amenities and infrastructure) Semi-rural (Moderate population density, balanced amenities, mixed residential-commercial areas.) Urban (High density, extensive amenities, developed infrastructure) Not able to assess 🎯Topic A. Demographic Characteristics A6. Living arrangement Alone With family/others In a care facility In a care facility Not able to assess 🎯Topic A. Demographic Characteristics A7. Minority status Yes No Not able to assess 🎯Topic A. Demographic Characteristics A8. Community disaster impact Natural disaster (e.g., fire, flood) Unnatural disaster (e.g., war, conflict) Not particularly Not able to assess 🎯Topic B. Health & Comorbidities B1. Number of chronic illnesses 1-3 diseases 4 or more No diseases Not able to assess 🎯Topic B. Health & Comorbidities B2. Number of medications taken No medications 1-2 medications 3-5 medications more than 5 medications 🎯Topic B. Health & Comorbidities B3. Mobility Able to drive Unable to drive (no aids) Using mobility aids Not able to assess 🎯Topic B. Health & Comorbidities B4. Mental disorder diagnosis Yes No Maybe Not able to assess 🎯Topic B. Health & Comorbidities B5. Family history of mental health disorders Yes No Maybe Not able to assess 🎯Topic B. Health & Comorbidities B6. Mental health professionals Yes No Not able to assess 🎯Topic B. Health & Comorbidities B7. Mental health professionals No Mild Moderate Severe 🎯Topic B. Health & Comorbidities B8. Hearing impairment Yes No Maybe Not able to assess 🎯Topic B. Health & Comorbidities B9. Visual impairment Yes No Maybe Not able to assess 🎯Topic C. Cognitive & Emotional Function C1. Memory problems Yes Occasionally Not really Not able to assess 🎯Topic C. Cognitive & Emotional Function C2. Use of money Independent Needs assistance Not able to assess 🎯Topic C. Cognitive & Emotional Function C3. Loss of loved one/close relative Yes No Not able to assess 🎯Topic C. Cognitive & Emotional Function C4. Difficulty making decisions Yes No Maybe Not able to assess 🎯Topic C. Cognitive & Emotional Function C5. Trauma Yes Possible No Not able to assess 🎯Topic C. Cognitive & Emotional Function C6. Speech/language difficulties Yes Possible No Not able to assess 🎯Topic C. Cognitive & Emotional Function C7. Confusion/delirium Yes Possible No Not able to assess 🎯Topic C. Cognitive & Emotional Function C8. Hallucinations Yes Possible No Not able to assess 🎯Topic D. Sleep & Nutrition D1. REM Sleep disorder Yes Possible No Not able to assess 🎯Topic D. Sleep & Nutrition D2. Insomnia Yes Possible No Not able to assess 🎯Topic D. Sleep & Nutrition D3. Over-sleep Yes Possible No Not able to assess 🎯Topic D. Sleep & Nutrition D4. Under-sleep Yes Possible No Not able to assess 🎯Topic D. Sleep & Nutrition D5. Weight changes (loss) Yes Possible No Not able to assess 🎯Topic D. Sleep & Nutrition D6. Weight changes (gain) Yes Possible No Not able to assess 🎯Topic D. Sleep & Nutrition D7. Dietary habits Optimal/close to optimal Suboptimal Poor/Very poor Not able to assess 🎯Topic E. Community and Lifestyle E1. Supportive network Yes A few Not really Not able to assess 🎯Topic E. Community and Lifestyle E2. Frequency of feeling lonely Never/rarely Sometimes Often Not able to assess 🎯Topic E. Community and Lifestyle E3. Exchange of visits Never/rarely Sometimes Often Not able to assess 🎯Topic E. Community and Lifestyle E4. Alcohol consumption Never/rarely Occasionally Regularly Not able to assess Topic E. Community and Lifestyle E5. Tobacco use Never In the past Current Not able to assess 🎯Topic E. Community and Lifestyle E6. Illicit drug use Never In the past Current Not able to assess 🎯Topic E. Community and Lifestyle E7. Engagement in hobbies or leisure activities Never/rarely Sometimes Often Not able to assess 🎯Topic E. Community and Lifestyle E8. Physical exercise routine Moderate/High Light Sedentary Not able to assess 🎯Topic F. Personal Space & Environment F1. Cleanliness of living space Clean Moderately clean Cluttered Not able to assess 🎯Topic F. Personal Space & Environment F2. Organization/tidiness of personal belongings Organised Moderately organised clean Disorganised Not able to assess 🎯Topic F. Personal Space & Environment F3. Hoarding tendencies Yes No Maybe Not able to assess 🎯Topic F. Personal Space & Environment F4. Personal hygiene and appearance Good Average Poor Not able to assess Next question ➜