I.

PATIENT’S BACKGROUND INFORMATION

Name:
Address:
Age:
Gender:
Birthday:
Birthplace:
Religion:
Occupation:
Civil Status:
Highest Educational
Attainment:
Monthly Income:

II. IDENTIFICATION OF PATIENTS NEEDING GERIATRIC ASSESSMENT

1. Who made the appointment?

2. Did your patient come in alone or with family members?

3. What brings the patient to the office? Who has the complaint or concern, the patient or
the family?

4. What is the chief complaint?

5. Does the patient appear to have lost weight or to be malnourished?

6. Can the elderly person walk alone or do they need support?

7. What kind of medication is the patient taking, both prescription and over-the-counter
(OTC)?
 KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

Activities Independence Dependence

Points (1 or 0) (1 Point) (0 Points)
NO supervision, direction or WITH supervision, direction,
personal assistance. personal assistance or total care.

BATHING (1 POINT) Bathes self completely (0 POINTS) Need help with

Points: __________ or needs help in bathing only a
single part of the body such as
the back, genital area or disabled
extremity.
DRESSING (1 POINT) Get clothes from
Points: __________ closets and drawers and puts on
clothes and outer garments
complete with fasteners. May
have help tying shoes.
TOILETING (1 POINT) Goes to toilet, gets on
Points: __________ and off, arranges clothes, cleans
genital area without help.
bathing more than one part of the
body, getting in or out of the tub o
(0 POINTS) Needs help with
dressing self or needs to be
completely dressed.
(0 POINTS) Needs help
transferring to the toilet, cleaning
self or uses bedpan or commode.

TRANSFERRING (1 POINT) Moves in and out of (0 POINTS) Needs help in moving

Points: __________ bed or chair unassisted. from bed to chair or requires a
Mechanical transfer aids are complete transfer.
acceptable

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

Points: __________ self-control over urination and incontinent of bowel or bladder
defecation.

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

TOTAL POINTS: ________ SCORING: 6 = High (patient independent) 0 = Low (patient

very dependent)
LAWTON - BRODY INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE
(I.A.D.L.)
Scoring: For each category, circle the item description that most closely resembles the client’s
highest functional level (either 0 or 1).
A. Ability to Use Telephone
1. Operates telephone on own initiative-
looks up and dials numbers, etc.
2. Dials a few well-known numbers
3. Answers telephone but does not dial
4. Does not use telephone at all
B. 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
C. Food Preparation
1. Plans, prepares and serves adequate
meals independently
2. Prepares adequate meals if supplied
with ingredients
3. Heats, serves and prepares meals, or
prepares meals, or prepares meals but
does not maintain adequate diet
4. Needs to have meals prepared and
served
D. Housekeeping
1. Maintains house alone or with
occasional assistance (e.g. "heavy work
domestic help")
2. Performs light daily tasks such as dish
washing, bed making
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
Score
A summary score ranges from 0 (low function, dependent) to 8 (high function,
independent) for women and 0 through 5 for men to avoid potential gender bias.
E. Laundry
1 1. Does personal laundry completely 2. 1
Launders small items-rinses stockings, etc. 1
1 3. All laundry must be done by others
1 0
0
F. Mode of Transportation
1 1. Travels independently on public 1
transportation or drives own car
0 2. Arranges own travel via taxi, but does 1
not otherwise use public transportation
0 3. Travels on public transportation when 1
accompanied by another
0 4. Travel limited to taxi or automobile with 0
assistance of another
5. Does not travel at all 0
G. Responsibility for Own Medications
1 1. Is responsible for taking medication in 1
correct dosages at correct time
0 2. Takes responsibility if medication is 0
prepared in advance in separate dosage
0 3. Is not capable of dispensing own 0
medication
0
A.Ability to handle Finances
1 1. Manages financial matters 1
independently (budgets, writes checks,
1 pays rent, bills, goes to bank), collects and
keeps track of income 0
2. Manages day-to-day purchases, but
1 needs help with banking, major purchases,
etc. 0
1 3. Incapable of handling money
0
Score
Total score__________________
 GET UP AND GO TEST AND TIMED GET UP AND GO
TEST
Assessment Observations YES NO
Is the person steady and balanced when sitting upright?

Is the person able to stand with the arms folded?

When standing, is the person steady in narrow stance?

With eyes closed, does the person remain steady?

When nudged, does the person recover without difficulty?

Does person start walking without hesitancy?

When walking, does each foot clear the floor well?

Is there step symmetry, with the step’s equal length and regular?

Does the person take continuous, regular steps?

Does the person walk straight without a walking aid?

Does the person stand with heels close together?

Is the person able to sit safely and judge distance correctly?

Is the person obviously fearful or anxious during assessment?

 MINI-MENTAL STATE EXAMINATION (MMSE)

Maximum Patient’s score Questions

score
5 “What is the year? Season? Date? Day of the
week? Month?”
5 “Where are we now: State? County? Town/city?
Hospital? Floor?”
3 The examiner names three unrelated objects
clearly and slowly, then asks the patient to name
all three of them. The patient’s response is used
for scoring. The examiner repeats them until
patient learns all of them, if possible. Number of
trials:
5 “I would like you to count backward from 100 by
sevens.” (93, 86, 79, 72, 65, …) Stop after five
answers. Alternative: “Spell WORLD backwards.”
(D-L-R-O-W)
3 “Earlier I told you the names of three things. Can
you tell me what those were?”
2 Show the patient two simple objects, such as a
wristwatch and a pencil, and ask the patient to
name them.
1 “Repeat the phrase: ‘No ifs, ands, or buts.’”

3 “Take the paper in your right hand, fold it in half,

and put it on the floor.” (The examiner gives the
patient a piece of blank paper.)
1 “Please read this and do what it says.” (Written
instruction is “Close your eyes.”)
1 “Make up and write a sentence about anything.”
(This sentence must contain a noun and a verb.)

1 “Please copy this picture.” (The examiner gives

the patient a blank piece of paper and asks
him/her to draw the symbol below. All 10 angles
must be present and two must intersect.)

30 TOTAL
GERIATRIC DEPRESSION SCALE: SHORT FORM
 Questions YES NO
Are you basically satisfied with your life?

Have you dropped many of your activities and interests?

Do you feel that your life is empty?

Do you often get bored?

Are you in good spirits most of the time?
Are you afraid that something bad is going to happen to you?
Do you feel happy most of the time?
Do you often feel helpless?

Do you prefer to stay at home, rather than going out and doing new things?

Do you feel you have more problems with memory than most?

Do you think it is wonderful to be alive now?

Do you feel pretty worthless the way you are now?

Do you feel full of energy?

Do you feel that your situation is hopeless?

Do you think that most people are better off than you are?
Score 1 point for each answer
TOTAL:
A score > 5 points is suggestive of depression.
A score ≥ 10 points is almost always indicative of depression.
A score > 5 points should warrant a follow-up comprehensive assessment.