Gerontology - Geriatric Assesment Form

University of Cebu
College of Nursing
Geriatric Assessment Form

Patient Name: Insurance No.
Primary Care Provider: Sex: Race:
Weight: Height: DOB: Age:
Present Illness:
History of Illness:
Surgical History:
Allergies:
Current Medications:
Assistive Devices:
Signs of Neglect/Abuse:
Activities of Daily Life Assessment

ADL Rating IADL Rating
Bathing _____________ Cooking _____________
Bowel/Bladder _____________ Cleaning _____________
Getting dressed _____________ Laundry _____________
Eating/Feeding _____________ Finances _____________
Taking medication _____________ Dialing the phone _____________
Shopping _____________ Physical Ambulation _____________
Memory Assessment
Problem Present? Problem Present?
General forgetfulness _____________ Driving _____________
Forgets names _____________ Job performance _____________
Forgets dates _____________ Speech _____________
Forgets messages _____________ Home safety _____________
Forgets family/friend _____________ Home cleanliness _____________
Gets lost _____________ Personality Changes _____________
Behavioral Assessment
Problem Present? Problem Present?
Anxious _____________ Suspicious _____________
Agitated _____________ Tearful _____________
Aggressive _____________ Hallucinations _____________
Cooperative _____________ Guarded _____________
Irritable _____________ Lost/wandering _____________
Impulsive _____________ Psychomotor functions _____________
Restless _____________ Resist’s care _____________
Observations
Appearance □Neat □Disheveled □Inappropriate □Bizarre □Other
Speech □Normal □Tangential □Pressured □Impoverished □Other
Eye Contact □Normal □Intense □Avoidant □Other

Motor
□Normal □Restless □Tics □Slowed □Other
Active
Affect □Full □Constricted □Flat □Labile □Other
Comments:
Cognition
Sensation
□Time □Place □Object □Person □Time
Impairment
Memory
□Time □Short-term □Long-term
Impairment
Attention □Normal □Distracted □Other
Comments:
GERIATRIC DEPRESSION SCALE (GDC, SHORT FORM)

Write YES or NO for how you felt over the past week.
1. Are you basically satisfied with your life? ___________
2. Have you dropped many of your activities and interest? ___________
3. Do you feel that your life is empty? ___________
4. Do you often get bored? ___________
5. Are you in good spirits most of the time? ___________
6. Are you afraid that something bad is going to happen to
you? ___________
7. Do you feel happy most of the time? ___________
8. Do you often feel helpless? ___________
9. Do you prefer to stay at home, rather than going out and
doing new things? ___________
10. Do you feel you have more problems with memory than
most? ___________
11. Do you think it is wonderful to be alive now? ___________
12. Do you feel pretty worthless the way you are now? ___________
13. Do you feel full of energy? ___________
14. Do you feel that your situation is hopeless? ___________
15. Do you think that most people are better off than you are? ___________
Over-all Assessment/Observation:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
___________________________________ _________________
Student’s name and signature Date
PHYSICAL SELF-MAINTENANCE SCALE (ACTIVITIES OF DAILY LIVING OR ADLs)
A. Bathing
1. Bathe’s self (tub, shower, sponge bath) without help
2. Bathes self with help getting in and out of tub
3. Washes face and hands only, but cannot bathe rest of body
4. Does not wash self, but is cooperative with those him or her clean
5. Does not try to wash self and resists efforts to keep him or her clean
B. Toilet
1. Care for self at toilet completely; no incontinence
2. Needs to be reminded, or needs help in cleaning self, or has rare
(weekly at most) accidents
3. Soiling or wetting while asleep more than once a week
4. Soiling or wetting while awake more than once a week
5. No control of bowels or bladder
C. Dressing
1. Dresses, undresses, and selects clothes from own wardrobe
2. Dresses and undresses self, with minor assistance
3. Needs moderate assistance in dressing and selection of clothes
4. Needs major assistance in dressing, but cooperates with effort of
other to help
5. Completely unable to dress self and resists effort of others to help
6. Always neatly dressed, well-groomed, without assistance
7. Grooms’ self adequately with occasional minor assistance, eg, with
shaving
8. Needs moderate and regular assistance or supervision with
grooming
9. Needs total grooming care, but can remain well-groomed after help
from others
10. Actively negates all efforts of others to maintain grooming
D. Feeding
1. Eats without assistance
2. Eats with minor assistance at meal times and/or with special
preparation of food, or help in cleaning up after meals
3. Feeds self with moderate assistance and is untidy
4. Requires extensive assistance for all meals
5. Does not feed self at all and resists efforts of others to feed him or
her
E. Responsibility for Own Medications
1. Is responsible for taking medication in correct dosages at correct
times
2. Takes responsibility if medication is prepared in advance in separate
dosages
3. Is not capable of dispensing own medication
F. Shopping
1. Takes care of all shopping needs independently
2. Shops independently for small purchases
3. Needs to be accompanied on any shopping trip
4. Completely unable to shop
G. Food Preparation
1. Plans, prepares, and serves adequate meals independently
2. Prepares adequate meals if supplied with ingredients
3. Heats and serves prepared meals or prepares meals, but does not
maintain adequate diet
4. Needs to have meals prepared and served
H. Housekeeping
1. Maintains house alone or with occasional assistance (eg, heavy-work
domestic help)
2. Performs light daily tasks such as dishwashing, bedmaking
3. Performs light daily tasks, but cannot maintain acceptable level of
cleanliness
4. Needs help with all home maintenance tasks
5. Does not participate in any housekeeping tasks
I. Laundry
1. Does personal laundry completely
2. Launders small items; rinses socks, stockings, etc.
3. All laundry must be done by others
J. Ability to Handle Finances
1. Manages financial matters independently (budgets, writes checks,
pays rent, and bills, goes to bank); collects and keeps track of
income
2. Manages day-to-day purchases, but needs help with banking, major
purchases, etc.
3. Incapable of handling money
K. Ability to Use Telephone
1. Operates telephone on own initiative; looks up and dials numbers
2. Dials a few well-known numbers
3. Answers telephone, but does not dial
4. Does not use telephone at all
L. Physical Ambulation
1. Goes about grounds or city
2. Ambulates within residence on or about one block distant
3. Ambulates with assistance of (check one)
a.( )another person, b.( )railing, c.( )cane, d.( )walker,
e.( )wheelchair
1. Gets in and out without help 2. Needs help getting in and out
4. Sits unsupported in chair or wheelchair, but cannot propel self
without help
5. Bedridden more than half the time

Gerontology - Geriatric Assesment Form

Uploaded by

Copyright:

Gerontology - Geriatric Assesment Form

Uploaded by

Document Information

Original Title

Copyright

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Gerontology - Geriatric Assesment Form

Uploaded by

Copyright:

University of Cebu

Geriatric Assessment Form

Activities of Daily Life Assessment

Speech □Normal □Tangential □Pressured □Impoverished □Other

Eye Contact □Normal □Intense □Avoidant □Other

GERIATRIC DEPRESSION SCALE (GDC, SHORT FORM)

You might also like