Professional Documents
Culture Documents
Cga - 1
Cga - 1
This is an interview administered questionnaire. For items nos. 1-37, 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.)
What is your highest educational attainment? (Ano po ang inyong pinakamataas na natapos sa pag-
aaral?)
__Farmer/Tricycle driver
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)
If Yes, what is it (Kung Oo, ano ito)? ✓ PhilHealth Other HMOs (Iba pang HMOs):
__________________
Son/Daughter (Anak)
Grandchild/children (Apo/Mga Apo)
Other relatives (Iba pang kamag-anak): ________________
Others (Iba pa):
_________________________________________________
_____________Asawa__________________
Telephone No.:
___________________________________________________________________________
What is your relationship to your primary caregiver (Ano po ang inyong relasyon sa
iyong pangunahing
tagapag-alaga)?
✓ Owned (Sarili/Pag-aari)
Rented (Nangungupahan)
Mortgage (Hulugan)
Shared renting (Nakikihati sa upa)
“Nakikitira”
Others (Iba pa): _________________
SOCIAL
Alumni ✓
Volunteer group
Informal
20.) What is your role in your family? (Ano po ang ginagampanang tungkulin sa inyong pamilya
(halimbawa: tagaluto, tagapag-alaga ng
apo)?______Padre de Palmilya________________
If Yes (Kung Oo), since when (kailan pa nagsimula)? ____Since 20 Years old____________
How many sticks per day (Ilang istik/piraso sa isang araw)? _5 Sticks_____
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)
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)?
Brisk walking
Running
Jogging
Swimming
✓ Cycling 2 times a week 30mins.
Dancing
Climbing stairs
Playing sports like tennis, volleyball, soccer, etc
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
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) watching tv_____
HEALTH (KALUSUGAN)
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
Fear of Falling
Are you afraid of falling (Natatakot po ba kayong mahulog o madapa)? ✓ Yes (Oo)
No (Hindi)
27.) 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?
If Yes, what is/are it/these? (Kung Oo, anu-ano po ang mga ito)?
Motoprolol 500mg OD
Losartan 500mg OD
Herbal medicines
Nutritional supplements
(Taon)
Influenza
Pneumococcal
Tetanus
Chicken Pox
Hepatitis B
Herpes zoster
Others (Iba pa): ________________
If Yes, what is/are it/these (Kung Oo, anu-ano po ang mga ito?)
35.) 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)
36.) 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)
General
✓ Weight Gain (Pagbigat ng timbang) □□□□kg Weight Loss (Pagbaba ng timbang) □□□□ kg
Gastrointestinal
✓ Dental Carries (Dental karis o may sira ang ngipin) ✓ Pain (Kirot)
Pulmonary
Cough (Ubo) Shortness of breath (Hingal)
Difficulty Breathing (Hirap sa paghinga) Others (Iba pa): ______________
Genitourinary
Dysuria (Hapdi o sakit sa pag-ihi) Dribbling (Paunti-unting pag-ihi)
Frequency (Madalas umihi) Nocturia (Madalas magising sa gabi para umiihi)
Bleeding (May pagdurugo) Others (Iba pa): _______________
Incontinence (Hindi mapigilan ang pag-ihi)
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)?
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)
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
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)
Neurologic
Using Vision aid: Yes (Oo) No (Hindi) Type: ✓ Eyeglasses (Salamin) Contact lens
(Pareho)
Balance
Cardiac
Speech/Language
Slurred (Nabubulol)
Dysarthria (Hirap sa pagsasalita) Others (Iba pa)
______________________
Musculoskeletal
1 0
Using the telephone (Paggamit ng ✓
Bathing (Pagligo) ✓
telepono)
Dressing (Pagbihis) ✓ Shopping (Pamimili)
Food preparation (Paghanda ng pagkain) ✓
Toileting (Pagbanyo) ✓
Housekeeping (Pag-ayos o paglinis sa
Transfers (Pagbangon) ✓ bahay)
Laundry (Paglalaba)
Continence (Pagpigil sa Transportation (Pagsakay) ✓
ihi o dumi)
Taking medicine (Pag-inom ng gamot) ✓
Feeding (Pagkain) ✓
Managing money (Pangangalaga ng pera) ✓
ADL Score 5 IADL Score 5
Physical Examination
Height (cm): __165cm__ Weight (kg): _75Kg___ BMI (kg/m2): 24.5__ *Proceed to MNA-SF if BMI is
<18.5 or >23
Hip circumference (cm): _____________ Waist circumference (cm): _95cm_______ WH
Ratio: 0.90__ Demi span (cm): R ___73 cm______ L ____73cm______ General:
Location
Vision Hearing
Chest/Lungs:
Heart/CVS:
Abdomen:
Neurological Examination
Fund of information:
______________________________________________________________
B. Cranial Nerves
Normal (-) Abnormal (+)
II. Fundus
Visual Fields
Visual Acuity
III, IV, VI
VII
VIII
IX, X
XII
elbow extensors 4 4
wrist flexors 3 3
wrist extensors 4 4
grip 3 3
hip flexors 4 4
hip extensors 4 4
knee flexors 4 4
knee extensors 4 4
foot dorsiflexors 4 4
foot plantarflexors 4 4
Fatigability
Presence of spontaneous movements:
Fasciculation Tremors
E. Reflexes
Remarks:
_______________________________________________
_______________________________________________
_______________________________________________
F. Sens
Normal Abnormal Findings a
Findings t
Normal Abnormal
Light touch ✓ i
Posture ✓o
Pain/temperature ✓ n
G. Functional reach ✓
Joint ✓
position/vibratory Time up and go test ✓
Summary of Findings
The Patient is a tricycle driver, he is 64 years old. and he has Hypertension. maybe because he
was on the road every day and exposed to the heat. and also inevitable due to aging. As we grow
older our vascular system changes. As a result, Our blood pressure increases. the reasons why He
became tricycle driver until now, is that they are poor and this is the available job for him
because He only reach 2nd year High school.
He is now with his wife and they have three Children but only his wife takes care of him because their
children have their own families as well.
________________________________
_____________________________
MD Signature over Printed Name