COMPREHENSIVE GERIATRIC ASSESSMENT FORM

Date of Assessment: _____________________

A. PERSONAL DATA ASSESSMENT
Advanced Health Directive Planning
DNR Directive:
Living Will:
Medical Power of Attorney:
Financial Health Planning
Primary source of healthcare:
Financial resources related to illness:

B. MEDICAL ASSESSMENT Justification/ Pathophysiological basis

Vital Signs
Temperature
Rate:
Route:
Peripheral pulse
Rate:
Rhythm:
Location:
Pulse amplitude:
Apical pulse
Rate:
Rhythm:
Murmurs:
Respirations
Rate:
Rhythm:
Use of accessory muscles:
Lung sounds:
General appearance:
Allergic reactions on
Medication:
Food:
Environment:
Vaccinations:
1.
2.
3.
Health promotion activities:
1.
2.
3.
Long term conditions:
1.
2.
3.
Regular clinics and therapies:
1.
2.
3.
Surgical history:
 1.
2.
3.
Eyes/ Vision
Eyes:
Pupil:
Use of glasses:
Ears/ Hearing
Hearing:
Hearing aid:
Skin integrity
Scar/s:
Wound/s:
Surgical incision/s:
Mucous membranes:
Airway clearance
Mouth:
Nose:
Color
Skin:
Nails:
Lips:
Capillary refill:
Oxygen therapy:

Braden Scale (Pressure Ulcer Risk) Score

Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction
Total
Interpretation

C. PHYSICAL AND FUNCTIONAL Justification/ Pathophysiological basis

ASSESSMENT
Current Activity:
Sleep:
Body Frame:
Coordination:
Muscle Strength
Right upper extremity:
Left upper extremity:
Right lower extremity:
Left lower extremity:
Motor
Fine:
Gross:
Range of Motion
Abduction:
Adduction:
Flexion:
Extension:
Pain
Provocation:
Palliation:
Quality:
Region:
Radiation:
Severity scale:
Time onset/ timing:

Morse Scale (Falls Risk) Score

Age
Fall History
Mobility
Elimination
Medications
Patient care equipment (IV, Feeding Tubes,
Indwelling Catheters, etc.)
Total
Interpretation

Basic Activities of the Daily Living

Activity Score
1. Bathing
2. Dressing
3. Toileting
4. Transferring
5. Continence
6. Feeding
Total
Interpretation

Instrumental Activities of the Daily Living

Activity Score
1. Telephone
2. Traveling
3. Shopping
4. Preparing meals
5. Housework
6. Medication
7. Money
8. Laundry
Total
Interpretation

Tinetti Balance Test

Activity Score
1. Sitting balance
2. Arising
3. Attempt to arise
4. Immediate standing balance (first 5 seconds)
5. Standing balance
6. Nudging
7. Eyes closed
8. Turning 360 degrees
9. Sitting down
Total
Interpretation

Tinetti Gait Test

Activity Score
1. Initiation of gait
2. Step length and height
3. Step symmetry
4. Step continuity
5. Path
6. Trunk
7. Walk stance
Total
Interpretation

D. NUTRITIONAL ASSESSMENT Justification/ Pathophysiological basis

Diet Restriction:
Fluid Intake:
Weight:
Height:
BMI:
Interpretation:
Skin turgor:
Gag reflex:
Swallow:
Appetite:
Food likes:
Food dislikes:
Elimination- bowel:
Stool
Frequency:
Consistency:
Color:
Elimination- bladder:
Urine
Frequency:
Color:
Amount:
Transparency:
Abdomen
Contour:
Bowel Sounds
Right lower:
Right upper:
Right upper:
Left lower:

Mini Nutritional Assessment- Screening

Screening Score
1. Has food intake declined over the past 3 months
due to loss of appetite, digestive problems,
chewing or swallowing difficulties?
2. Weight loss during last 3 months
3. Mobility
4. Has suffered psychological stress or acute disease
in the past 3 months
5. Neuropsychological problems
6. Body mass index (BMI)
-OR-
Calf circumference (CC) in cm
Total
Interpretation

Mini Nutritional Assessment

Assessment Score
1. Lives independently (not in a nursing home)?
2. Takes more than 3 prescription drugs per day
3. Pressure sores or skin ulcers
4. How many full meals does the patient eat daily?
5. Selected consumption markers for protein intake
 At least one serving of dairy products (milk,
cheese, yogurt) per day?
 Two or more servings of legumes or eggs per
week?
 Meat, fish or poultry every day?
6. Consumes two or more servings of fruit or
vegetables per day?
7. How much fluid is consumed per day?
8. Mode of feeding
9. Self- view of nutritional status
10. In comparison with other people of the same age,
how does the patient consider his/ her health
status?
11. Mid- arm circumference (MAC)
12. Calf circumference (CC)
Total
Total Score of MNA-Screening and
Assessment
Interpretation

E. PSYCHOLOGICAL/ PSYCHIATRIC Justification/ Pathophysiological basis

ASSESSMENT
Level of Consciousness
Eyes:
Verbal:
Motor:
Orientation
Person:
Place:
Time:
Memory
Immediate:
Recent:
Remote:
Health attitude:
Nonverbal Behaviors:
Mini Mental State Examination
Questions Score
“What is the year? Season? Date? Day? Month?”
“Where are we now? State? County? Town/city?
Hospital? Floor?”
The examiner names three unrelated objects clearly
and slowly, then the instructor 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.
“I would like you to count backward from 100 by
sevens.”
Alternative: “Spell WORLD backwards.”
“Earlier I told you the names of three things. Can
you tell me what those were?”
Show the patient two simple objects, such as a
wristwatch and a pencil, and ask the patient to name
them.
“Repeat the phrase: ‘No ifs, ands, or buts.’”
“Take the paper in your right hand, fold it in half, and
put it on the floor.”
“Please read this and do what it says.”
“Make up and write a sentence about anything.”
“Please copy this picture.”

Total
Interpretation

Geriatric Depression Scale

Question Score
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and
interests?
3. Do You feel that your life is empty?
4. Do you often get bored?
5. Are you hopeful about the future?
6. Are You bothered by thoughts you can't get out of
your head?
7. Are you in good spirits most of the time?
8. Are you afraid that something bad is going to
happen to you?
9. Do you feel happy most of the time?
10. Do you often feel helpless?
11. Do you often get restless and fidgety?
12. Do you prefer to stay at home rather than go out
and do things?
13. Do you frequently worry about the future?
14. Do you feel you have more problems with
memory than most?
15. Do you think it is wonderful to be alive now?
16. Do you feel downhearted and blue?
17. Do you feel worthless the way you are now?
18. Do you worry a lot about the past?
19. Do you find life very exciting?
20. Is it hard for you to get started on new projects?

21. Do you feel full of energy?

22. Do you feel that your situation is hopeless?
23. Do you think that most people are better off than
you are?
24. Do you frequently get upset over little things?
25. Do you frequently feel like crying?
26. Do you have trouble concentrating?
27. Do you enjoy getting up in the morning?
28. Do you prefer to avoid social occasions?
29. Is it easy for you to make decisions?
30. Is your mind as clear as it used to be?
Total
Interpretation

F. SOCIAL- ENVIRONMENT ASSESSMENT Justification/ Pathophysiological basis

Name of Caregiver:
Caregiver relationship:
Caregiver stress:
Significant others:
Social engagement
Occupation:
Current activities indoor:
Current activities outdoor:
Pets:
Personal safety concerns:
Home safety concerns:
History of Abuse
Emotional:
Sexual:
Physical:
Smoking Habit
Age started:
Age stopped:
Number of cigars a day:
Alcohol Abuse
Type:
Frequency:
Hobbies and Favorite Activities: