RIVERSIDE COLLEGE, INC.

www.riverside.edu.ph

GERIATRIC ASSESSMENT TOOL

I. Biographic Data

Patient Name: ____________________________________ Age: __________ Sex: __________

Height: __________ Weight: _________ Date of Birth: _________________________________
Place of Birth: ________________________ Nationality: _______________________________
Religion: ____________________________ Status: ___________________________________

Primary Care Provider:

______________________________________________________________________________
Reason of Admission:
______________________________________________________________________________
Surgical History:
______________________________________________________________________________
Current Medication:
______________________________________________________________________________

II. History of past illness:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

III. History of present illness:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100
 RIVERSIDE COLLEGE, INC.
www.riverside.edu.ph
IV. General Appearance
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

V. Heredo-familial Diseases

Disorders Maternal Paternal

Diabetes
Hypertension
Asthma
Cancer (indicate what kind of cancer)
Heart Disease
Epilepsy
Rheumatism / Arthritis

VI. Acquired Diseases

Disorder Yes No
Hypercholesterolemia
Kidney Disease
Tuberculosis
Alcoholism
Drug Addiction
Hepatitis

VII. Vital Signs

DATE
TEMP
PULSE
RESPI
BP

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100
 RIVERSIDE COLLEGE, INC.
www.riverside.edu.ph
VIII. Immunization Status

VACCINE YES NO YEAR BOOSTER

Influenza
Pneumococcal
HEP B
COVID – 19

IX. Assistive Devices

Device Yes No
Cane
Walker
Wheelchair
Other, pls. specify

X. Communication

Speech Hearing Vision

Within normal limits or impaired Within normal limits or impaired Within normal limits or impaired
Nurse observation Nurse observation Nurse observation

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100
 RIVERSIDE COLLEGE, INC.
www.riverside.edu.ph
XI. Physical Observation
Scalp: signs of injury or abnormalities
Nurse observation:

Hair: inspect for dryness or alopecia

Nurse observation:

Eyes: inspect: color, shape, symmetry

Nurse observation:

Ears: inspect: color, shape, symmetry, interior inspection

Nurse observation:

Nose: no abnormalities observed

Nurse observation:

Chest: no visible deformities

Nurse observation:

Abdomen: soft and Non-tender, no distension

Nurse observation:

Gait: steady and coordinated

Nurse observation:

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100
 RIVERSIDE COLLEGE, INC.
www.riverside.edu.ph
SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ) version 1
QUESTION RESPONSE INCORRECT
RESPONSE
1. What are the date, month, and year?
2. What is the day of the week?
3. What is the name of this place?
4. What is your phone number?
5. How old are you?
6. When were you born?
7. Who is the current president?
8. Who was the president before him?
9. What was your mother’s maiden name?
10. Can you count backward from 20 by 3’s?
Total Errors

Scoring NOTE ON SCORING:

0-2 errors: normal mental functioning
3-4 errors: mild cognitive impairment
5-7 errors: moderate cognitive impairment
8 or more errors: severe cognitive impairment
One more error is allowed in the scoring
if a patient has had a grade school
education or less. One less error is
allowed if the patient has had education
beyond the high school level.

Source: Folstein F. (1975). A short portable mental status questionnaire for the assessment of
organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41.

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100
 RIVERSIDE COLLEGE, INC.
www.riverside.edu.ph

KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

ACTIVITIES INDEPENDENCE DEPENDENCE

Points (1 or 0) (1 Point) (0 points)
NO supervision, direction or personal WITH supervision, direction,
assistance personal assistance or total care.
BATHING (1 POINT) Bathes self completely or (0 POINTS) Needs help with
needs help in bathing only a single part bathing more than one part of the
POINTS: of the body such as the back, genital area body, getting in or out of the tub or
_________ or disabled extremity. shower. Requires total bathing.
DRESSING (1 POINT) Gets clothes from closets and (0 POINTS) Needs help with
drawers and puts on clothes and outer dressing self or needs to be
POINTS: garments complete with fasteners. May completely dressed.
_________ have help tying shoes.

TOILETING (1 POINT) Goes to toilet, gets on and (0 POINTS) Needs help

off, arranges clothes, cleans genital area transferring to the toilet, cleaning
POINTS: without help. self or uses bedpan or commode.
_________

TRANSFERRING (1 POINT) Moves in and out of bed or (0 POINTS) Needs help in moving
chair unassisted. Mechanical transferring from bed to chair or requires a
POINTS: aides are acceptable. complete transfer.
_________

CONTINENCE (1 POINT) Exercises complete self- (0 POINTS) Is partially or totally

control over urination and defecation. incontinent of bowel or bladder.
POINTS:
_________

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

TOTAL SCORE ______ A score of 6 indicates full function, 4 indicates moderate

impairment, and 2 or less indicates severe functional impairment.

Source: try this: Best Practice in Nursing Care to Older Adults, The Hartford Institute for
Geriatric Nursing, New York University, College of Nursing. www.hartfordign.org.

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100
 RIVERSIDE COLLEGE, INC.
www.riverside.edu.ph

Geriatric Depression Scale

(Short Form)

Patient’s Name: ______________________________________ Date: _____________________

Instructions: Choose the best answer for how you felt over the past week.
No. Questions Answer Score
1 Are you basically satisfied with your life? Yes/No
2 Have you dropped many of your activities and interests? Yes/No
3 Do you feel that your life is empty? Yes/No
4 Do you often get bored? Yes/No
5 Are you in good spirits most of the time? Yes/No
6 Are you afraid that something bad is going to happen to you? Yes/No
7 Do you feel happy most of the time> Yes/No
8 Do you often feel helpless? Yes/No
9 Do you prefer to stay at home, rather than going out and doing Yes/No
new things?
10 Do you feel you have more problems with memory than most? Yes/No
11 Do you think it is wonderful to be alive? Yes/No
12 Do you feel pretty worthless the way you are now? Yes/No
13 Do you feel full of energy? Yes/No
14 Do you feel that your situation is hopeless? Yes/No
15 Do you think that most people are better off than you are? Yes/No
TOTAL

SCORING:
Assign one point for each of these answers:
1. No 4. Yes 7. No 10. Yes 13. No
2. Yes 5. No 8. Yes 11. No 14. Yes
3. Yes 6. Yes 9. Yes 12. Yes 15. Yes

A score of 0 to 5 is NORMAL. A score above 5 suggests depression.

Source:
Yesavage J.A, Brink T.L., Rose T.L. et al. Development and validation of a geriatric depression
screening scare: a preliminary report. J. Psychriatr. Res. 1983; 17;37-49.

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100