Developed by the Institute on Aging-NIH UP Manila, Philippine College of Geriatric Medicine, and NCGH DOH

Comprehensive Geriatric Screening

This is an interview administered questionnaire. For items nos. 1-40, please supply the information asked for.
(Pagsagot sa talatanungan sa tulong ng tagapanayam. Pakipunan ng tamang mga impormasyon ang bawat isang
tanong mula sa bilang isa hanggang tatlumput-pito.)

1.) Date (Petsa): _____________________

2.) File No.: ___________________________
3.) Interviewer (Tagapanayam): __________________________
DEMOGRAPHICS (DEMOGRAPIYA)

4.) Name (Pangalan): __________________________________ Nickname (Palayaw): ______________________

5.) Age in years (Edad): _________________ 6.) Sex (Kasarian): Male (Lalaki) Female (Babae)
7.) Address (Tirahan): _____________________________________________________________________________
8.) Place of birth (Lugar ng Kapanganakan): ___________________________________________________________
9.) Telephone no. (Numero ng telepono): _________________ Mobile no. (selfon) : __________________________
10.) Civil Status (Katayuang Sibil)
Single (Walang Asawa) Widow (Balo)
Married (May Asawa) Separated/Divorced (Hiwalay sa Asawa)

11.) Highest Educational Attainment (Pinakamataas na Natapos sa Pag-aaral)

What is your highest educational attainment? (Ano po ang inyong pinakamataas na natapos sa pag-aaral?)
Postgraduate (Pagkatapos ng Kolehiyo) High school level (Hayskul)
College Graduate (Tapos ng Kolehiyo) Elementary Graduate (Tapos ng elementarya)
College Level (Kolehiyo) Elementary (Elementarya)
High school graduate (Tapos ng hayskul)

12.) Occupational History

Are you retired? (Kayo po ba ay retirado na?) Yes (Oo) No (Hindi)
Note: If the answer is NO, please refer to 12.B.
A. If Yes, what was your previous occupation (Kung retirado na, ano po ang inyong dating trabaho?)
_________________________________________________________________________________

B. If No, are you currently working? (Kung Hindi, kayo po ba ay nagtatrabaho sa kasulukuyan)?
Yes (Oo) No (Hindi)
If Yes, what is your occupation (Kung Oo, ano po ang inyong trabaho)?
_________________________________________________________________________________

13.) List of Financial Resources (Listahan ng Pinansiyal na Pinagkukunan)

Note: Select all that apply.
Where do you get your finances to support your daily expenses?
(Saan po nanggagaling ang inyong pang- araw araw na panggastos)?
Salary (Sweldo) Consultancy (Sangguni)
Pension (Pensiyon): SSS Business (Sariling negosyo)
GSIS
Foreign
Others: ___________
Financial support from (Suportang pinansiyal mula sa): Wife (Asawang babae)
Husband (Asawang lalaki)
Child/Chilldren (Anal/Mga anak)
Other relatives (Iba pang kamag-anak)
Others (Iba pa): ________________
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14.) Adequacy of Finances

Are your finances enough to support your daily expenses (Sapat ba ang inyong kinikita upang matustusan
ang inyong pang-araw araw na gastos)? Yes (Oo) No (Hindi)
Are you worried about your ability to support your healthcare needs (Nangangamba k aba sa iyong
kakayahang suportahan ang inyong pangangailangang pangkalusugan)? Yes (Oo) No (Hindi)

15.) Health Insurance

Do you have a health insurance (Mayroon po ba kayonghealth insurance)? Yes (Oo) No (Hindi)
If Yes, what is it (Kung Oo, ano ito)? PhilHealth Other HMOs (Iba pang HMOs): __________________

16.) Living Arrangement (Kalagayan sa Pamumuhay)

Are you (Kayo po ba ay..) Living alone (Namumuhay mag-isa)
Living with others (Namumuhay ng may kasama)
With whom (Kasama ang..)? Spouse (Asawa)
Son/Daughter (Anak)
Grandchild/children (Apo/Mga Apo)
Other relatives (Iba pang kamag-anak): ________________
Others (Iba pa): _________________________________________________

17.) Primary caregiver (Pangunahing Tagapag-alaga)

Do you have a primary caregiver (Kayo po ba ay may pangunahing tagapag-alaga)? Yes (Oo) No (Hindi)
If Yes, who is your primary caregiver (Kung meron, sino po ang inyong pangunahing tagapag-alaga)?
_________________________________________________
Primary Caregiver’s address: ________________________________________________________________
Telephone No.: ___________________________________________________________________________

What is your relationship to your primary caregiver (Ano po ang inyong relasyon sa iyong pangunahing
tagapag-alaga)?
Wife (Asawang babae) Son (Anak na lalake)
Husband (Asawang lalake) Daughter (Anak na babae)
Son in law (Manugang na lalake) Grandson (Apong lalake)
Daughter in law (Manugang na babae) Granddaughter (Apong babae)
Professional caregiver (Propesyonal na Tagapag-alaga) Others: ___________________

18.) Housing (Pagpapabahay)

What is the state of your housing (Ano po ang kalagayan ng inyong tirahan o lupa)?
Owned (Sarili/Pag-aari)
Rented (Nangungupahan)
Mortgage (Hulugan)
Shared renting (Nakikihati sa upa)
“Nakikitira”
Others (Iba pa): _________________

SOCIAL

19.) Social Activities (Gawaing Panlipunan)

Formal (Pormal) YES (Oo) NO (Hindi)
Are you a member of (Kayo po ba ay kasapi ng..)?
Church groups (Samahan sa simbahan)
Alumni
Volunteer group
Senior citizen’s organization (Samahan ng mga nakakatanda)
Informal
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You are interacting with your.. (Kayo po ay nakikipag-ugnayan o nakikisalamuha sa inyong..)

Children (Mga anak) Sibling/s (Kapatid) Grandson/daughter (Mga apo)
Friend/s (Kaibigan) Neighbor (Kapitbahay) All of the above (Lahat ng nabanggit)
Others (Iba pa): _____________________________

20.) What is your role in your family? (Ano po ang ginagampanang tungkulin sa inyong pamilya (halimbawa:
tagaluto, tagapag-alaga ng
apo)?___________________________________________________________________________________

21.) Lifestyle and Self-Care

A. Have you ever smoked (Nakapagsigarilyo na po ba kayo)? Yes (Oo) No (Hindi)
Are you a (Kayo po ba ay)? Current Smoker (Kasalukuyang naninigarilyo) Previous Smoker (Dating
naninigarilyo): (Kailan pa po kayo huminto sa paninigarilyo?)___________________
If Yes (Kung Oo), since when (kailan pa nagsimula)? ________________
How many sticks per day (Ilang istik/piraso sa isang araw)? __________

B. Have you ever taken alcohol (Kayo po ba ay nakainom na ng alak)? Yes (Oo) No (Hindi)
Are you a (Kayo po bay ay)? Current drinker (Kasalukuyang umiinom) Previous drinker (Dating
umiinom): (Kailan pa po kayo huminto sa pag-inom ng alak?)___________________

C. Have you ever taken illicit drugs (Kayo po ba ay nakagamit ka na ba ng ipinagbabawal na gamot)?
Yes (Oo) No (Hindi)
Are you a (Kayo po bay ay)? Current drug user (Kasalukuyang gumagamit ng bawal na gamot)
Previous drug user (Dating gumagamit ng bawal na gamot): (Kailan pa po kayo
huminto sa pag-gamit ng ipinagbabawal na gamot?)___________________

D. Do you drink coffee (Kayo po ba ay umiinom ng kape)? Yes (Oo) No (Hindi)

Are you a (Kayo po bay ay)? Current drinker (Kasalukuyang umiinom)
Previous drinker (Dating umiinom): (Kailan pa po kayo huminto sa pag-inom ng
kape?)___________________

E. Do you drink tea (Kayo po ba ay umiinom ng tsaa)? Yes (Oo) No (Hindi)

Are you a (Kayo po bay ay)? Current drinker (Kasalukuyang umiinom)
Previous drinker (Dating umiinom) (Kailan pa po kayo huminto sa pag-inom ng
tsaa?)___________________

Others (Iba pa) ______________________ (e.g. nganga)

PHYSICAL ACTIVITY (Gawaing Pisikal)

22.) Exercise
Do you exercise (Kayo po ba ay nag-eehersisyo)? Yes (Oo) No (Hindi)
What type of exercise do you do (Ano pong uri ng ehersisyo ang ginagawa niyo)?
Aerobic and endurance Frequency Duration

Brisk walking
Running
Jogging
Swimming
Cycling
Dancing
Climbing stairs
Playing sports like tennis, volleyball, soccer, etc
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Others: _________________________

Balance and flexibility Frequency Duration

Yoga
Taichi
Pilates
Basic (Static) stretches

Strength training
Weight lifting
Lunges
Squats
Crunches
Wall push ups
Others: ______________

23.) Leisure
Do you engage in leisure activities (Kayo po ba ay may ginagawa sa mga pagkakataong may libreng
panahon)? Yes (Oo) No (Hindi)
If Yes, please specify your leisure activity/ies (Kung Oo, pakitukoy): _________________

24.) Hobbies
Do you have a hobby (Kayo po ba ay mayroong libangan)? Yes (Oo) No (Hindi)
If Yes, please specify you hobby/ies (Kung Oo, pakitukoy): _________________

HEALTH (KALUSUGAN)

25.) History of Fall

In the past 3 months, have you experienced fall? (Sa nakaraang tatlong buwan, kayo po ba ay nakaranas na
ng pagkadapa, pagkahulog,o pagkatapilok?) Yes (Oo) No (Hindi)
Circumstances surrounding the fall (Ano po ang kalagayan o mga bagay bagay na naging sanhi ng inyong
pagkahulog): ____________________________________________________________________
Did you seek medical treatment after the fall (Kayo po ba ay kumunsulta sa manggagamot matapos
mahulog)? Yes (Oo) No (Hindi)
Post fall consequences (Resulta ng Pagkahulog) Yes (Oo) No (Hindi)
Loss of Consciousness (Kayo po ba ay nawalan ng malay?)
Physical Injury (Pisikal na pinsala tulad ng?)
Sprain (Pilay)
Fracture (Pagkabali sa buto)
Others (Iba pa): _______________________________________________________________

Fear of Falling
Are you afraid of falling (Natatakot po ba kayong mahulog o madapa)? Yes (Oo) No (Hindi)

26.) Consultation with Healthcare provider

Kayo po ba ay nagpapatingin sa tagapagbigay ng pangangalagang pangkalusugan? Yes (Oo) No (Hindi)
If Yes, to whom (Kung Oo, kanino)? __________________________________________________________

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27.) Chief Complaint:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

28.) History of Present Illness

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

29.) Medical Illness/ Problem List (List of Acute and Chronic Illness, Allergies, etc.)
Sa inyong pagkakaalam, anu-ano po ang inyong mga sakit ayon sa inyong doktor?

Medical Illness Date Started Date Resolved Course of Action

(Sakit) (Petsa ng Pagsisimula) (Petsa ng Pagresolba) (Mga ginawang aksyon)
Year (Taon) Year (Taon)

__________________________________ _________________ _________________ _____________________

__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________
__________________________________ _________________ _________________ _____________________

30.) Medication History (Including prescription, non-prescription, herbal, and nutritional supplements)
Are you taking any medication within the past two weeks (Kayo po ba ay umiinom ng gamot nitong nakaraang
dalawang lingo?) Yes (Oo) No (Hindi)

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If Yes, what is/are it/these? (Kung Oo, anu-ano po ang mga ito)?
Medications Dosage Frequency

Herbal medicines

Nutritional supplements

31. Alternative Therapies

Acupuncture
Chelation
Others: ___________________________________

32.) Immunizations
Have you ever been vaccinated as an adult (Kayo po ba ay nabakunahan na ngayong nagka-edad na)?
Yes (Oo) No (Hindi)
If Yes, what is/are it/these (Anu-ano po ang mga ito)?
Date of Immunization Year
(Taon)
Influenza
Pneumococcal
Tetanus
Chicken Pox
Hepatitis B
Herpes zoster
Others (Iba pa): ________________

33.) Family Medical History

(Anu-ano po ang mga sakit sa inyong pamilya?)
Tuberculosis (Tuberkulosis) Asthma (Hika)
Coronary Artery Disease (Sakit sa puso) Hypertension (Altapresyon)
Cerebrovascular disease (Istrok) Dementia ex. Alzheimer’s disease

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Cancer (Kanser)
Diabetes Mellitus (Diyabetis) Others: _____________________

34.) For women only: (Para sa mga kababaihan lamang)

Age at menopause (Ano po ang inyong edad ng huminto ang inyong regla): ____________
Menopause (Paghinto ng regla) Natural (natural) Surgical (operasyon)
HRT use (Kayo po ba ay gumamit ng hormone therapy): Yes (Oo) No (Hindi)
Previous use of OCP (Kayo po ba ay gumamit ng kontraseptibo)? Yes (Oo) No (Hindi)
Kayo po ba ay nakapagpa-Pap smear na? Yes (Oo) No (Hindi)
If Yes (Kung Oo), results (ano po ang resulta): ______________
Kayo po ba ay nakapagpa-Mammogram na? Yes (Oo) No (Hindi)
If Yes (Kung Oo), results (ano po ang resulta): ______________
Kayo po ba ay nagpasuri sa buto tulad ng Dexa Screening? Yes (Oo) No (Hindi)
Peripheral Central T score _______

35.) Past Surgical Procedures

Have you ever undergone surgery/operation? (Kayo po ba ay ma mga napagdaanan ng mga operasyon)?
Yes (Oo) No (Hindi)
If Yes, what is/are it/these (Kung Oo, anu-ano po ang mga ito?)

Surgical Procedures Year (Taon)

36.) Self-Rated Health (Q#1):

(Pansariling Pananaw sa
Kalidad ng Buhay)
How would you rate
your current state of health
(Paano niyo ituturing ang

pangkasalukuyang estado ng iyong kalusugan)?

[1] [2] [3] [4] [5]
Poor Fair Good Very good Excellent
(Mahina) (Katamtaman) (Mabuti) (Mabuting-mabuti) (Napakabuti)

37.) Sleep
Overall, in the past month, have you experience problems with sleeping such as falling asleep, waking up
frequently during the night or waking up early (Sa nakalipas na buwan, kayo po ba ay nagkaroon ng problema
sa pagtulog tulad ng hirap sa agad na pagtulog, madalas na paggising sa pagtulog, o maagang paggising sa
umaga)? Yes (Oo) No (Hindi)

38.) Depression
During the past month, have you been bothered by feeling down, depressed or hopeless (Sa nakalipas na
isang buwan, kayo po ba ay nakaramdam ng pagkalungkot, pagkalumbay, o kawalan ng pag-asa sa buhay)?
Yes (Oo) No (Hindi)
* If Yes, proceed to GDS

39.) REVIEW OF SYTEMS

Considering the past 3 months, select all that apply and write details if applicable. Sa nakalipas na tatlong buwan,
kayo po ba ay nakaranas ng…

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General
Weight Gain (Pagbigat ng timbang) □□□□kg Weight Loss (Pagbaba ng timbang) □□□□ kg
No weight changes (Walang pagbabago sa timbang) Fever (Lagnat)
Fatigue (Pagod) Loss of appetite (Walang ganang kumain)
Others (Iba pa): ________________________

Gastrointestinal
Dental Carries (Dental karis o may sira ang ngipin) Pain (Kirot)
Dentures (may pustiso) Constipation (Nagtitibi)
Edentulous (wala ng ngipin) Diarrhea (Nagtatae)
Loss of taste (Walang lasa sa pagkain) Incontinence (Hindi mapigilan and pagdumi)
Dysphagia (Hirap na paglunok o nasasamid) Melena (May bahid ng dugo ang dumi)
Odynophagia (Masakit ang paglunok) Hematochezia (May dugo sa dumi)
Vomiting(Pagsusuka) Hemorrhoids (Almoranas)
Hematemesis (Pagsuka ng dugo) Others (Iba pa): ______________
Nausea (Naduduwal)

Pulmonary
Cough (Ubo) Shortness of breath (Hingal)
Difficulty Breathing (Hirap sa paghinga) Others (Iba pa): ______________

Genitourinary
Dysuria (Hapdi o sakit sa pag-ihi)
Frequency (Madalas umihi)
Bleeding (May pagdurugo)
Incontinence (Hindi mapigilan ang pag-ihi)
Dribbling (Paunti-unting pag-ihi)
Nocturia (Madalas magising sa gabi para umiihi)
Others (Iba pa): _______________

Sexual
You may choose not to answer the following questions on sexual activity (Maaring hindi ninyo po sagutan ang mga
sumusunod na tanong tungkol sa pagtatalik).
For men: Are you sexually active (Kayo po ba ay aktibo pa sa pakikipagtalik)? Yes (Oo) No (Hindi)
Do you have problems with erection (Mayroon po bang problema sa pagtigas ng ari)?
Yes (Oo) No (Hindi)
Do you engage in safe sex (Kayo po ba ay nakikipagtalik ng may pag-iingat)? Yes (Oo) No (Hindi)
If Yes, what do you use (Kung Oo, ano po ang inyong ginagamit)? _________________________________

For women: Are you sexually active (Kayo po ba ay aktibo pa sa pakikipagtalik)? Yes (Oo) No (Hindi)
Do you have problems with sexual intercourse (Mayroon po bang problema tuwing nakikipagtalik)?
Yes (Oo) No (Hindi)
Do you feel any pain during the intercourse (Nakakaramdam po ba kayo ng sakit tuwing nakikipagtalik)?
Yes (Oo) No (Hindi)
Do you engage in safe sex (Kayo po ba ay nakikipagtalik ng may pag-iingat)? Yes (Oo) No (Hindi)
If Yes, what do you use (Kung Oo, ano po ang inyong ginagamit)? _________________________________

Gynecologic
Discharge (Lumalabas sa pwerta) Prolapse (Prolaps o buwa)
Bleeding (May pagdurugo) Others (Iba pa: _______________________)
Pruritus (Pangangati)

Psychiatric
Confusion (Nagugulumihanan) Anxiety (Kaba o nerbiyos)
Memory Loss (Pagkalimot) * If Yes, proceed to MMSE Agitation (Pagkataranta)
Wandering (Pagala-gala o napunta sa ibang lugar ng hindi alam kung papaano makabalik)
Depression (Nakakramdam ng kalungkutan) Paranoia (Lubos na paghihinala)
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Neurologic
Syncope (Nawalan ng malay) Numbness (Pamamanhid)
Tremors (Nanginginig) Bradykinesia (Mabagal na paggalaw)
Paralysis (Naparalisa) “Pasma”, describe (ilarawan) __________________
“Nangangalay”, describe (ilarawan) _______________
Vision
(Ang inyong mga mata po ba ay..)
Blurred (Malabo, maulap, o mausok)
Using Vision aid: Yes (Oo) No (Hindi) Type: Eyeglasses (Salamin) Contact lens Both (Pareho)
Floaters (Bagay na palutang-lutang sa paningin) Tearing (Nagluluha)
Blind Spots (Mayroong parte na hindi makita) Redness (Namumula)
Photopsia (mga gumuguhit na ilaw) Glare (nasisilaw)
Eye pain or heaviness (Masakit o mabigat sa pakiramdam) Itchy (Nangangati)
Foreign body sensation (pakiramdam na may nakapuwing sa mata)

Ears and Hearing

Hearing problem (Kayo po ba ay may problema sa pandinig) Yes (Oo) No (Hindi)
Use of hearing aid (Kayo po ba ay gumagamit ng tulong pandinig)? Yes (Oo) No (Hindi)
Tinnitus (Tinitus o may umuugong sa tenga) Ear pain (Masakit ang tenga)
Ear discharge (May lumalabas sa tenga) Itchiness (Pangangati)
Others (Iba pa)

Balance
Dizziness (nahihilo) Vertigo (naliliyo o umiikot ka o ang paligid)
Imbalance or disequilibrium (parang natutumba o diniduyan)

Cardiac
Palpitations (nakakaramdam ng palpitasyon) Chest Pain (Pananakit ng dibdib)
Dyspnea (nahihirapan sa paghinga) Easy fatigability (Madaling mapagod)
Orthopnea (Ortopniya o parang nalulunod sa tuwing nakahiga) Pedal Edema (Namamanas ang paa)
Others, (Iba pa) ____________________

Speech/Language
Slurred (Nabubulol)
Dysarthria (Hirap sa pagsasalita) Others (Iba pa) ______________________

Musculoskeletal
“Artritis”: _____________________ Muscle wasting/atrophy (nangunguluntoy ang kalamnan)
“Rayuma”: ____________________ Muscle tone/stiffness (Naninigas ang mga kalamnan)
Musculoskeletal pain (Sakit sa buto o kalamnan): Joint pain: __ Neck __ Back __ Hip __Other site: _______

Activities of Daily Living (ADL)

Physical ADLs
1 0

Bathing (Pagligo)

Dressing (Pagbihis)

Toileting (Pagbanyo)

Transfers (Pagbangon)

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Continence (Pagpigil sa Instrumental ADLs
ihi o dumi)
Feeding (Pagkain) 1 0
Using the telephone (Paggamit ng
ADL Score telepono)
Shopping (Pamimili)
Food preparation (Paghanda ng pagkain)
Housekeeping (Pag-ayos o paglinis sa
bahay)
Laundry (Paglalaba)
Transportation (Pagsakay)
Taking medicine (Pag-inom ng gamot)
Managing money (Pangangalaga ng pera)
IADL Score

Physical Examination

BP (mmHg): Standing: ______ Sitting: ______ HR (bpm): _____ RR: ______

Height (cm): _____ Weight (kg): ____ BMI (kg/m2): _______ *Proceed to MNA-SF if BMI is <18.5 or >23
Hip circumference (cm): _____________ Waist circumference (cm): _____________ WH Ratio: ______________
Demi span (cm): R ________________ L _______________
General:
Pain Yes (Oo) No (Hindi)

Location

VISUAL ANALOG SCALE (VAS)

0 10
NO PAIN SEVERE PAIN

HEENT:
Vision Hearing
Visual acuity: ______________________ Rinne’s test: __________________________
Gross examination: _________________ Weber’s test: _________________________
Otoscopic exam: _______________________
Chest/Lungs:

Heart/CVS:

Abdomen:

Spine and Extremities:

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Neurological Examination

A. Mental Status Examination

1. General behavior and appearance: Normal Hyperactive Agitated Quiet Immobile

Neat Slovenly
Do clothes match the patient’s age, peers, sex, background? Y N
2. Stream of thought: Does the patient converse normally? Y N Repetitive? Y N
3. Speech: Rapid Incessant Under great pressure Lack spontaneity and prosody
4. Language: Is the patient discursive, tangential, and unable to reach the conversational goal? Y N
5. Mood and affective responses: Euphoric Agitated Giggling Silent Weeping Angry
Is the mood appropriate? Y N
Is the patient emotionally labile? Y N
6. Content of thought: Illusions Hallucinations Delusions Misinterpretations
Does the patient suffer delusions of persecution and surveillance by malicious persons or forces?
Y N
Is the patient preoccupied with bodily complaints, fears of cancer or heart disease, or other phobias?
Y N
7. Intellectual capacity: Bright Average Dull Obviously demented Mentally retarded
8. Sensorium: Consciousness: __________________________________________________________________
Attention span: ___________________________________________________________________
Orientation for time, place, and person: ______________________________________________
Memory (recent and remote): _______________________________________________________
Fund of information: ______________________________________________________________
Insight, judgement, and planning: ____________________________________________________
Calculation: _____________________________________________________________________
B. Cranial Nerves
Normal (-) Abnormal (+)

II. Fundus

Visual Fields

Visual Acuity

III, IV, VI

VII

VIII

IX, X

XII

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C. Manual muscle testing D. Motor Exam

Grading (0-5) Muscle strength: ____________________________

Muscle group R L Extrapyramidal: ____________________________
Muscle atrophy/hypertrophy: _________________
neck flexors Muscle tone: Spastic Rigid Flaccid
Passive movement of the joint
shoulder abductors Slowness and reduce
spontaneity
shoulder adductors Endurance: ____________________
Fatigability
elbow flexors Presence of spontaneous movements:
Fasciculation Tremors
elbow extensors

wrist flexors
E. Reflexes
wrist extensors

grip

hip flexors

hip extensors

knee flexors

knee extensors

foot dorsiflexors

foot plantarflexors

Remarks:
_______________________________________________
_______________________________________________
_______________________________________________

F. Sensation
Normal Abnormal Findings G. Coordination and Gait
Findings Normal Abnormal
Light touch
Posture
Pain/temperature
Functional reach
Joint
position/vibratory Time up and go test

Cerebellar signs

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40. Summary of Findings

________________________________

Signature over Printed Name

_____________________________MD
Signature over Printed Name

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