West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

GERIATRIC HEALTH ASSESSMENT

I. BIOLOGICAL INFORMATION

Name (Initials only): Date and Time of Interview:

Age: Informant:
Sex: Relationship to Patient:
Civil Status:
Date of Birth:
Address:
Religious Affiliation:
Educational Attainment:
Occupation:
Approximate Monthly Income of the Family:
Allergies:

Vital Signs

Date and Time Taken:

Temperature:
Blood Pressure:
Pulse Rate:
Respiratory Rate:

Height:
Weight:

II. NURSING HISTORY

Usual Health Status:

1. Past Medical History (pls. specify whether it is acute or chronic illness)

Neurosensory:
Musculoskeletal:
Cardiovascular:
Respiratory:
GIT:
Endocrine:
Urinary:
Reproductive:
Emotional Disorder:
Integumentary:
Accidents/Injuries:
Others (specify):

1
 2. No. of Previous Hospitalization

Date of last confinement:

Name of Hospital:
Duration of hospitalization:
Reason(s) for confinement
(include laboratories, diagnostics tests and
surgical operating performed):

3. Heredo-familial Diseases (specify)

4. Medications (note all prescribed and OTC medications)

III. FUNCTIONAL ASSESSMENT

a) CURRENT MEDICATIONS
List of Medications Purpose/Reason for use Side effects

Any monitoring activities? ______ NO _______ YES If yes, specify ________________

b) ELIMINATION PATTERNS
Frequency Problems Usual remedy
Defecation
Urination

c) SLEEP-REST PATTERNS
Usual Naptime No. of Pillows Bedtime Problems Usual Remedy
Bedtime (including (Dimension Rituals
frequency and and placement)
duration)

d) NUTRITION-METABOLIC PATTERNS

HYDRATION PATTERN
Kinds of fluid taken Total amount of Problems / difficulties
Fluid taken/24 H (in range)

Total Intake:

2
EATING PATTERN
Usual Food Taken Time of Day Problems/
(quantity and type of Difficulties
food, preparation)

Breakfast

Lunch

Dinner

Snacks

Any special diet? NO YES If yes, specify _______________________

Nutritional supplements (specify) :

e) ACTIVITY, EXERCISE AND RECREATION

Description Time of Day and Duration

Exercise (include time of day and
duration)
Recreational / Diversional
Activities
Usual Activities of Daily Living:
Any limitations in ADLs (medical/physical):
Use of Assistive Devices:

f) PERSONAL HABITS

TYPE Age Started and Time of Day Frequency

(Specify the amount at
ml./day for alcohol and no. of
packs/sticks/day for
cigarettes)
TOBACCO
ALCOHOL
STREET DRUGS

g) COGNITIVE-PERCEPTUAL PATTERNS

Description Problems/ Difficulties

Memory
Communication
Orientation
Self-Perception/Self-
Concept

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 h) ROLE-RELATIONSHIP/ SOCIALIZATION

Family, friends
neighbors, etc.
Any mistreatment, abuse,
violence, neglect

i) HEALTH SUPERVISION (including immunization status)

V. PHYSICAL ASSESSMENT

General Appearance: (posture and gait, over-all hygiene and grooming, body and breath odor in
relation to activity level, signs of distress in posture or facial expression, obvious signs of health or
illness)

A. Skin, Hair, and Nails

B. Head, Face, Neck, and Lymphatic

C. Eyes, Ears, Nose, Mouth, and Throat

D. Chest, Breast, and Axilla

E. Thorax and Lungs/ Respiratory System

F. Heart and Cardiovascular System

G. Abdomen/ Gastrointestinal System

H. Genitalia/ Genito-urinary System/ Anal Area

I. Upper/Lower Extremities/ Musculoskeletal System

J. Neurological Assessment

IV. FUNCTIONAL ASSESSMENT

The Barthel Index

Bowels
0= incontinent (or needs to be given enemata)
1= occasional accident (once/week)
2= continent
Patient's Score:

Bladder
0= incontinent, or catheterized and unable to manage
1= occasional accident (max. once per 24 hours)
2= continent (for over 7 days)
Patient's Score:

4
Grooming
0= needs help with personal care
1= independent face/hair/teeth/shaving (implements provided)
Patient's Score:

Toilet use
0=dependent
1= needs some help, but can do something alone
2= independent (on and off, dressing within reach)
Patient's Score:

Feeding
0= unable
1= needs help cutting spreading butter, etc.
2= independent (food provided within reach)
Patient's Score:

Transfer
0= unable-no sitting balance
1= major help (one two people, physical), can sit
2=minor help (verbal or physical)
3= independent
Patient's Score:

Mobility
0=immobile
1= wheelchair independent, including corners, etc.
2= walks with help of one person (verbal or physical)
3= independent (but may use any aid, e.g., stick)
Patient's Score

Dressing
0= dependent
1= needs help, but can do about half unaided
2= independent (including button, zips, laces, etc.)
Patient's Score:

Stairs
0=unable
1=needs help (verbal, physical, carrying aid)
2= independent up and down
Patient's Score:

Bathing
0=dependent
1=independent (or in shower)
Patient's Score:

Total Score:
(Collin et al., 1988)

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 Katz Index of Independence in Activities of Daily Living

Independence Dependence
Activities (1 Point) (0 Points)
Points (1 or 0) NO supervision, direction or WITH supervision, direction, personal
personal assistance assistance or total care
BATHING (1 POINT) Bathes self (0 POINTS) Need help with bathing more
Points: completely or needs help in than one part of the body, getting in or out
__________ bathing only a single part of of the tub or shower. Requires total bathing
the body such as the back,
genital area or disabled
extremity
DRESSING (1 POINT) Get clothes from (0 POINTS) Needs help with dressing self
Points: closets and drawers and puts or needs to be completely dressed.
__________ on clothes and outer garments
complete with fasteners. May
have help tying shoes.
TOILETING (1 POINT) Goes to toilet, gets (0 POINTS) Needs help transferring to the
Points: on and off, arranges clothes, toilet, cleaning self or uses bedpan or
__________ cleans genital area without commode.
help.
TRANSFERRING (1 POINT) Moves in and out (0 POINTS)Needs help in moving from bed
Points: of bed or chair unassisted. to chair or requires a complete transfer.
__________ Mechanical transfer aids are
acceptable
CONTINENCE (1 POINT) Exercises (0 POINTS) Is partially or totally
Points: complete self control over incontinent of bowel or bladder
__________ urination and defecation.

FEEDING (1 POINT) Gets food from (0 POINTS) Needs partial or total help with
Points: plate into mouth without help. feeding or requires parenteral feeding.
__________ Preparation of food may be
done by another person.

Total Points: ________

Score of 6 = High, Patient is independent.
Score of 0 = Low, patient is very dependent.