TAGUM DOCTORS COLLEGE, INC.

Mahogany St., RabeSubd., Tagum City

E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

NURSING DEPARTMENT

A. Name:  Sex:

Age: Race/Ethnicity:

Date of admission/or first contact: Referral source:

Previous occupation or present employer:

GERIATRIC ASSESSMENT TOOL

BODY PARTS NORMAL ACTUAL FINDINGS INTERPRETATION

FINDINGS

INTEGUMENTARY

SKIN

FINGERNAILS AND
TOENAILS

HEAD AND NECK

Head and Neck

Nose and

Sinuses

Nose

Sinuses

Mouth Pharynx and

Mouth Pharynx and

Eyes and Ears

Eyes

Ears

Cardiopulmonary

Heart and Vascular

Thorax and Lungs

Gastrointestinal
 Abdomen

Nutritional and

Metabolic Pattern

Genitourinary

Genitourinary and
Gynecologic

Breast

Musculoskeletal

Neurologic

Mental and

Emotional Status

Cranial Nerve

Function

Sensory Function

Motor Function

B.  SOCIOCULTURAL ASSESSMENT

Name:  Sex:

Age: Race/Ethnicity:

Date of admission/or first contact: Referral source:

Previous occupation or present employer:

I. Identifying data

II. Environment

III: Socioeconomic Level and Life-Style

IV: FAMILY PATTERNS

V.Family Functions and Interactions:

VI: RELIGIOUS PRACTICES

VII: MEMBERSHIPS
VIII : PERSONAL VALUES  (consider expressed ideal vs. real)

a. What are your ideas about the following:

Man and the environment relationship?

Privacy vs. group interaction (being with others)?

Possessions (personal vs. shared)?

b.  Time orientation:

Do you like to have things done promptly?

Do you rely on past experiences primarily?

Do you like to plan ahead into the future?

How do you feel if you know that you or someone else is going to be late to an event?

 c. Work or Activity – Leisure Orientation:

How much time do you spend in work tasks daily?

Do you prefer to be busy?  Sitting and thinking; Reading or relaxing?

What do you do to relax?

How much time do you spend in leisure daily?

 d. Attitude toward change:

e. Education:

f. Health-Illness Value or Definitions:

Activities of Daily Living Survey

Independent Needs assistance,describe type of assistance needed Dependent

Bathing (yes) Any Comments (yes)

Dressing (yes) Any Comments (yes)

Toileting * (yes) Any Comments (yes)

Feeding (yes) Any Comments (yes)

Transferring (yes) Any Comments (yes)

Ambulating (yes) Any Comments (yes)

Turning in Bed (yes) Any Comments (yes)

*Describe whether person can ask to be taken to bathroom or is totally incontinent.

C. PSYCHOLOGICAL ASSESSMENT

I. Identifying Data:

Name: Sex:

Age: Race/Ethnicity:

Marital Status: Children:

 Where Employed:  Occupation (past, present):

Ever active in a different occupation?

If yes, why did you change occupations?  When?

Other members in household:

Date of admission/first contact?  Referral source?

 II. Health History:

III. Life-Style Patterns:

IV. Perceptual Ability:

V.    Emotional Status:

● Self concept:

● Ego ideal:

● Super ego

VI. What rules or customs are difficult for you to follow?

VII. What do you consider the most important teachings that were given to you by your parents or family?

VIII. That you have lived by?

IX. What causes you to feel guilty?

X.Relations to others:

XI.Sense of autonomy:

How has aging or illness or hospitalization or admission to nursing home or residence affected your feelings of
control or lack of control?

Reaction and coping with situations:

Adaptive pattern:

What do you find best relieves your tension – eating, smoking, drinking, drubs, sleep, activity etc?

XII.    Use of Leisure:

XIII.    Communication Pattern: (Observe and listen for)

XIV.   Cognitive Status:  (Observe and listen for)