UNIVERSITY OF SANTO TOMAS HOSPITAL
España Blvd., Manila 1015
Tel No. (632)731-3001 to 29; http://www.usthospital.com.ph
DEPARTMENT OF MEDICINE
GERIATRIC ASSESSMENT FORM
Patient
Name
Private Division
Clinical Division
Date:
Last Name:
First Name:
Male
Middle Name:
Female
Birthdate:
In Patient Out Patient
Age:
A. FUNCTIONAL ABILITY ASSESSMENT
Katz Index of Independence in Activities of Daily Living
Write the corresponding points (0 or 1) based on the functional ability assessment of the patient
Activity
Independence (1 Point)
Dependence (0 Point)
Bathing
Bathes self completely or needs help in bathing
only a single part of the body, such as the back,
genital area or disabled extremity
Needs help with bathing more than one part
of the body, getting in our out of the tub or
shower. Requires total bathing
Dressing
Gets clothes from closets and drawers and puts
on clothes and outer garments complete with
fasteners. May have help tying shoes
Needs help with dressing self or needs to be
completely dressed
Toileting
Goes to toilet, gets on and off, arranges clothes,
cleans genital area without help
Needs help transferring to the toilet,
cleaning self, or uses bedpan or commode
Moves in and out of bed or chair unassisted.
Mechanical transferring aides are acceptable
Needs help in moving from bed to chair or
requires a complete transfer
Exercises complete self-control over urination and
defecation
Is partially or totally incontinent of bowel or
bladder
Gets food from plate into mouth without help.
Preparation of food may be done by another
person
Needs partial or total help with feeding or
requires parenteral feeding
Transferring
Fecal & urinary
continence
Feeding
Points
( 6 = independent 0 = very dependent) TOTAL POINTS 
Lawton Instrumental Activities of Daily Living Scale (Self-Rated Version)
For each question, circle the points for the answer that best applies to the situation of the patient
A. Ability to Use Telephone
1. Operates telephone on own initiative; looks up and dials
number………………………………………………………………………….…….1
2. Dials a few well-known numbers…………………………………………1
3. Answers telephone, but does not dial……………………………….…1
4. Does not use telephone at all………………………………………….……0
B. Shopping
1. Takes care of all shopping needs independently…………..…….1
2. Shops independently for small purchases…………………….….….0
3. Needs to be accompanied on any shopping trip………….….…..0
4. Completely unable to shop…………………………………………….…...0
C. Food Preparation
1. Plans, prepares and serves adequate meals independently…..1
2. Prepares adequate meals if supplied with ingredients…………..0
3. Heats and serves prepared meals or prepares meals but
does not maintain adequate diet……………………………………………0
4. Needs to have meals prepared and served………………………….…0
E. Laundry
1. Does personal laundry completely……………..……………..…1
2. Launders small items, rinses socks, stockings, etc……......1
3. All laundry must be done by others………………………..…....0
F. Mode of Transportation
1. Travels independently on public transportation
or drives own car…………………………………………………………......1
2. Arranges own travel via taxi, but does not otherwise
use public transportation……………………………………………….…1
3. Travels on public transportation when assisted or
accompanied by another………………………………………….……….1
4. Travel limited to taxi or automobile with assistance of
another……………………………………………………………………..……..0
5. Does not travel at all……………………………………………...…………0
G. Responsibility for Own Medications
1. Is responsible for taking medication in correct
dosages at correct time………………………………………………….…1
2. Takes responsibility if medication is prepared in
advance in separate dosages……………………………….………....0
3. Is not capable of dispensing own medication…………………..0
041018-MD-ME-TRIALCODE-F16 rev 1
D. Housekeeping
H. Ability to Handle Finances
1. Maintains house alone with occasion assistance
(heavy work)………………………………………………………………………….1
2. Performs light daily tasks such as dishwashing, bed
making…………………………………………………………………………………...1
3. Performs light daily tasks, but cannot maintain acceptable
level of cleanliness……………………………………………………….…………1
4. Needs help with all home maintenance tasks………………………..1
5. Does not participate in any housekeeping tasks……………….…..0
1. Manages financial matters independently (budgets,
writes checks, pays rent and bills, goes to bank);
collects and keeps track of income………………..………………..1
2. Manages day-to-day purchases, but needs help
with banking, major purchases, etc…………………………….….…1
3. Incapable of handling money……………………………………….……0
(1 = Highly Functional 0 = Low Functional Status) TOTAL POINTS
TOTAL FUNCTIONAL ABILITY ASSESSMENT
.
B. FALL RISK ASSESSMENT
Categories
Recent Fall History
Ambulation/Continence
Circle reference
number(s) in
each category
0
2
4
0
2
4
0
Mental Status
Vision
Balance
To assess, have patient stand on both feet without holding
onto anything; walk straight forward; walk through a
doorway; and make a turn.
2
4
0
2
4
0
1
1
1
1
1
1
1
0
Blood Pressure (Systolic)
2
4
0
Medications
Diuretics, Psychoactives, Benzodiazepines, Phenothiazines,
Antidepressants, Antipsychotics, Narcotics, Anticonvulsants,
Cardiovascular medications, Corticosteroids, or any
medication that adversely affects muscle function,
coordination, and physical stability.
Predisposing Conditions or Diseases
GASTROINTESTINAL: Bleeding, Diarrhea, Defecation
Syncope, Postprandial Syncope
GENITOURINARY: Micturition Syncope, Incontinence,
Nocturia
CARDIOVASCULAR: Myocardial Infarction, Arrhythmia,
Orthostatic Hypotension
MUSCULOSKELETAL DISORDERS: Arthritis, Inflammatory
Joint Disease, Osteoarthritis, Proximal Myopathy,
Deconditioning
NEUROLOGIC: Parkinsonism, Dementia, Stroke, TIA,
Delirium, Myopathy, VBI, Carotid Sinus Supersensitivity,
Cerebellar Disorder, Peripheral Neuropathy, DM, MM,
Vasculitis, Chronic Dehydration
2
4
1
Description
No Falls in past 3 months
1-2 Falls in past 3 months
3 or More Falls in past 3 months
Ambulatory/Continent
Chair Bound- Requires assist with elimination
Non-Ambulatory/Incontinent
Alert (oriented x3) or Comatose (no voluntary or
involuntary movement)
Disoriented X3 at all times
Intermittent Confusion/ forgets limitations
Adequate (with or without glasses)
Poor (with or without glasses)
Legally Blind
Gait/Balance Normal
Balance problem while standing
Balance problem while walking
Decreased muscular coordination
Change in gait pattern when walking through doorway
Unstable when making turns
Requires uses of assistive devices (i.e., canes,
wheelchair, walker, furniture)
Inappropriate use as assistive device/ footwear
No Noted Drop (between lying and standing)
Drop Less Than 20mmHg between lying and standing
in 3 minutes
Drop More Than 20mmHg between lying and standing
in 3 minutes
None of these medications taken currently or within
last 7 days
Takes 1-2 of these medications currently and/or
within last 7 days
Takes 3-4 of these medications currently and/or
within last 7 days
If patient has had a change in medications and/or
change in dosage in the past 5 days = score 1 additional
point
0
None Present
2
1-2 Present
4
3 or More Present
A TOTAL SCORE OF 10 OR MORE INDICATES A PATIENT “AT RISK”
FOR FALLS
Total reference
numbers by
category
TOTAL SCORE
The material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the center for Medicare Services (CMS), an agency of the U.S. Department of
Health and Human Services. The contents presented do not necessarily reflect CMS Policy. 10SOW-NY-AIM7-2-11-24
041018-MD-ME-TRIALCODE-F16 rev 1
C. MINI-MENTAL STATE EXAMINATION (MMSE) FILIPINO VERSION
Maximum
Score
5
Patient’s
Score
5
3
Questions
Ano petsa ngayon? (1 point) Buwan? (1 point) Taon? (1 point) Araw? (1 point) Panahon? (1 point)
Ano pangalan ng lugar na ito? (1 point) Nasaang palapag tayo ngayon? (1 point) Kalye? (1 point) Siyudad o
Munisipyo? (1 point) Bansa? (1 point)
Magsasabi ako ng tatlong bagay. Ulitin niyo ang tatlong ito pagkatapos kong sabihin. Tandaan din ninyo
ang mga ito dahil ipapaulit ko ito mamaya.
(3 trials) MANGGA BOLA PERA
5
Baybayin niyo ang salitang K-A-R-N-E. Pagkatapos baybayin ninyo ng pabaligtad ang mga letra ng salitang
K-A-R-N-E. Record Responses: ___ ___ ___ ___ ___
3
Ano-ano ang tatlong bagay na pinatandaan ko sa inyo kanina? Record Response: ______ ______ ______
Ano ang tawag dito? (Ituro and lapis o bolpen)
Ano ang tawag dito? (Ituro ang relo)
Ulitin ninyo ang sasabihin kong ito. “Wala nang papero-pero pa.”
Gawin ninyo ang sasabihin ko, Pakinggan ninyo bago gawin.
Kunin ninyo ang papel gamit ang inyong kanan/kaliwang kamay (non-dominant) kamay, tiklupin sa gitna
(o kalahati), at ilagay iyo sa inyong kandungan.
Basahin ninyo ito at gawin niyo ang sinasabi. IPIKIT MO ANG IYONG MATA.
Magsulat kayo ng isang pangungusap.
Kopyahin ninyo ito.
2
1
3
1
1
1
30
TOTAL
Interpretation of the MMSE
Method
Score
Interpretation
Single Cutoff
<24
Abnormal
Range
<21
>25
Increased odds of dementia
Decreased odds of dementia
Education
21
<23
<24
Abnormal for 8 grade education
Abnormal for high school education
Abnormal for college education
Severity
24-30
18-23
0-17
th
No cognitive impairment
Mild cognitive impairment
Severe cognitive impairment
Reference: Folstein MF, Folstein SE, McHugh PR: “Mini-mental state: A pratical method for grading the cognitive state of patients for the clinician.” J Psychiatr Res 1975; 12: 189-196.
D. CONFUSION ASSESSMENT METHOD (CAM)
Acute onset and fluctuating
course
No
Yes
Uncertain
Specify: _________________
Is there evidence of an acute
change in mental status from
the patient’s baseline? If so did
the abnormal behaviour
fluctuate during the day?
e.g. tend to come and go, or
increase and decrease in
severity
Inattention
No
Yes
Uncertain
Specify: _________________
Did the patient have difficulty
focusing attention during the
interview?
e.g. being easily distracted, or
having difficulty keeping track of
what was being said?
Disorganised thinking
No
Yes
Uncertain
Specify: _________________
Was the patient’s thinking
disorganised or organised?
e.g. Rambling or irrelevant
conversation, unclear or illogical
flow of ideas, or unpredictable
switching from one subject to
another?
Altered level of consciousness
No
Yes
Uncertain
Specify: _________________
Overall, how would you rate the
patient’s level of consciousness?
Altered e.g. Vigilant, Lethargic,
Stupor, Coma, Uncertain.
Delirium is present if features 1 and 2 AND either 3 or 4 are present
Delirium symptoms:
 not present
present
Date:
Medical Officer notified? Yes
No
Adapted with permission from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann
Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide, Copyright © 2003, Hospital Elder Life Program, LLC.
041018-MD-ME-TRIALCODE-F16 rev 1
E. PATIENT HEALTH QUESTIONNAIRE -9 (PHQ-9)
OVER THE LAST 2 WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY ANY
OF THE FOLLOWING PROBLEMS?
(Please encircle your answer)
NOT AT
ALL
SEVERAL
DAYS
MORE
THAN HALF
THE DAYS
NEARLY
EVERYDAY
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
NOT
DIFFICULT
AT ALL
SOMEWHAT
DIFFICULT
VERY
DIFFICULT
EXTREMELY
DIFFICULT
3.
4.
5.
6.
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself- or that you are a failure or have let yourself or
your family down
7. Trouble concentrating on things, such as reading the newspaper or
watching television
8. Moving or speaking so slowly that other people could have noticed? Or the
opposite- being so fidgety or restless that you have been moving around a
lot more than usual
9. Thoughts that you would be better off dead or hurting yourself in some
way
SUBTOTAL
TOTAL
If you checked off any problems, how difficult have those problems made it
for you to do your work, take care of things at home, or get along with other
people?
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant rom Pfizer Inc.
List of medications currently being taken or have taken within the past 7 days inclusive of herbal supplements and vitamins:
Social history and financial support:
Assessment:
Goals of care and advance care preferences:
Prepared by:
_________________________________________
Clinical Clerk / Postgraduate Intern
(Signature over Printed Name)
Noted by:
_____________________________________________
Medical Resident / Consultant
(Signature over Printed Name)
041018-MD-ME-TRIALCODE-F16 rev 1