Geriatric Assessment Sheet

Kingdom of Saudi Arabia ‫المملكة ال عر بية الس عودية‬
Ministry of Education ‫و زا رة الت علي م‬

Taibah University ‫جامعة ط يبة‬
College of Nursing
‫كلية ال تم ر ي ض‬
GERIATRIC ASSESSMENT SHEET
STUDENT
NAME ACADEMIC NO.
INSTRUCTION: Fill out this assessment sheet completely. Write N/A for items not
relevant to the geriatric client.
Part I. Personal Data

Name: Ahmed Age: 75
Gender: meal Marital Status: marry
Level of Education/ Educational Attainment: Bachelors
Occupation before Retirement: teacher
Financial Status (income adequate for lifestyle and/or health concerns):
Yes he have adequate income
Part II. Past Health History

Previous Hospitalization (if YES, please fill-out the table below):
DATE/S REASON/S MEDICAL DIAGNOSIS

5/6/2007 Swelling in the leg inguinal hernia
Common Illness/Sickness experienced:
Surgeries/Operations (if YES, please fill-out the table below):

DATE/S AGE DURING SURGERY REASON
5/6/2020 60 Swelling in the leg
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Allergies (if YES, please fill out the table):

BODILY REACTION TO THE
TYPE OF ALLERGEN SPECIFIC ALLERGEN
ALLERGEN
Banana itchy skin
Food/s
NON
Medication/s
NON
Pollen/s
Part III. Present History
Present Sickness/Illness:
Present Medication/s:
NAME OF MEDICINE/S ACTION OF DOSAGE & NURSING
MEDICINE/S FREQUENCY PRECAUTIONS WITH
MEDICATION
Compliance with Medication: Compliant (yes) noncompliant ( )

Causes of noncompliance:
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Part IV. Family History [if YES, please indicate who in the family (father, grandfather,
brother, etc.)
Heart Disease: Respiratory Disease:

Stroke: Obesity:
Diabetes: Father and Mother GIT Disorders:
Hypertension: Cancer:
Kidney Disease: Musculoskeletal Disease:
Other (please specify):
Part V. Review of Body Systems
A. Vital Signs:
Temp: 37oC
Resp Rate: 15 /min
Pulse: 88 /min
Blood Pressure:
 Sitting:112/80 mmHg
 Lying:100/82 mmHg
 After standing for three minutes: mmHg
Weight: 60 kg
Height: 165 cm
B. Integumentary System
Normal Age related Changes Pathological Changes

Skin
Hair
Nails
C. Head and Neck
Eyes:
Wearing eye glasses: Yes ( ) No( )
Problem or complaint:
Ears:
Hearing: Normal (yes) Impaired ( )
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Nose:
Smell: Normal (yes ) Impaired ( )
Lips: Normal: Yes ( yes) No ( )

Teeth:
Status: Decay ( ) Partial loss ( ) Total loss ( )
Dentures: Complete ( ) upper ( ) Lower ( )
Gums:
Pain ( ) Bleeding ( ) Inflamed ( )
Tongue:
Normal ( ) Coated ( ) Dry ( ) Others:
Neck:
Range of motion:
Pain ( ) Distended neck vein ( )
D. Thorax, Heart, and Lungs
Describe problems related to:

- Respiratory system:
- Circulatory system:
E. Gastrointestinal
Usual elimination Pattern:

Constipation: Acute ( ) Chronic ( ) Duration:
Diarrhea: Frequency: Duration:
Describe problems R/TGIT:
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F. Urinary
CRITERIA ACTUAL FINDINGS INTERPRETATION

Frequency of Urination
Color of Urine
Discomforts during Urination
G. Musculoskeletal
Level of mobility: mobile ( ) mobile with assistance ( ) bed ridden ( )
Need assistance: person ( ) cane ( ) walker ( ) wheel chair ( )
Problems: (Describe site, limitation) :
Part VI. Health Promotion and prevention practice:
A. Exercise Pattern (type, amount per day or week, method of monitoring body’s
response to exercise):
B. Nutrition:
- Type of diet consumed by the elderly:
1. Ordinary diet ( )
2. Therapeutic diet:
Low salt diet ( ) Diabetic diet ( ) Low fat diet ( )
3. others:
- Number of meals consumed/day:
- Usual amount of fluid intake:
- Food preferences(specify):
- Eating in group ( ) Eat alone ( )
C. Rest and sleep:
1. Usual sleep and rest pattern:
Day time: At night: : Total hours: :
2. Sleep disturbance: Yes ( ) No ( )
3. Source of sleep disturbance:
4. Medicine used to induce sleep:
D. Routine medical checkup: Yes ( ) No ( )

Results of last medical checkup:
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E. Personal Habits (if applicable only)
1. Cigarette Smoking? Yes ( ) No ( )

No. of cigarettes per day: Age started:
Ever tried to quit? How did it go?
2. Caffeine consumption: Yes ( ) No ( )
Type: Amount /day:
3. Others (specify):
Part VII: Falls and Balance evaluation
A. Timed Up and Go (TUG) Test

Ask the elderly to perform the following series of movements
1. Stand from the chair
2. Walk 3 meters on a line on the floor at your normal pace
3. Turn around
4. Walk back to the chair at your normal pace
5. Sit down
6. On word “go” begin timing
7. Stop timing after the elderly has sat back down and record the time in the file:
Time: seconds
Scoring of Timed Up and Go (TUG) Test:
 If the elderly completed the test in 10 sec: the elderly is not at risk of fall
 If the elderly completed the test in ≥ 20 sec: the elderly has a high risk of falls and
required referral
B. Balance test: Romberg’s test

Elderly stands up, shoes off with his legs closed, and he closes his eye and extends his hands.
If he loses balance the test is positive.
Result:
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Part VIII. Functional Status Assessment

1. Activities of Daily Living
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2. Instrumental Activities of Daily Living
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Part IX. Cognitive Assessment
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Part X. Psychological Assessment

Geriatric Depression Scale (Short Form)
Patient’s Name: Date:
Instructions: Choose the best answer for how you felt over the past week. Note: when asking the patient to
complete the form, provide the self-rated form (included on the following page).
Scoring:
Answers indicating depressionare in boldand italicized; score one point for eachone selected. A scoreof 5 or more suggests
depression.
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Part XI. Social assessment

Family APGAR
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Part XII: Environmental Assessment

CRITERIA YES NO N/A
Stairs
Do all stairwells have securely-fixed handrails on both sides?
Do the handrails extend beyond the length of the steps?
Does your hand easily wrap completely around the rail?
Are there lights & light switches at both the top and bottom of the stairs?
Can you clearly see the outline of each step as you ascend & descend the
stairs?
Do the stairs have even surfaces? (I.e. no metal strips or rubber mats to
trip on; in good repair?)
Are stairs clutter (i.e. dirt, thrash, obstruction) free?
Halls/Entrance
Are all carpets and runners well-fastened down? Does the carpet lay flat?
Is furniture positioned to allow full access to doorways with assistive
devices?
Are walkways clear of tripping hazards: cords, toys, low furniture, etc.?
Is there a nightlight lighting the path to the bathroom?
Do rugs stay put (don't slide or roll) when you push them with your foot?
Living Room
Does your chair have armrests that are long enough to help you get up or
down?
Can you turn on a light without having to walk into a dark room?
Are lamps, extension cords, & phone cords out of the flow of foot traffic?
Do you have easy access to a telephone?
Kitchen
Do you use non-skid wax, or no wax at all, on polished floors?
Are rugs non-skid?
Can you reach the most-often used items without a step-stool?
Is there adequate lighting?
Are your stove/oven controls easy to use?
Are curtains and towels away from burners?
Bedroom
Is there a nightlight, lamp, or flashlight in reach of your bed?
Is there a working smoke detector?
Is there a phone within reach of the bed?
Is the bed height appropriate (too high or low)?
Can you easily access needed dresser drawers?
Bathroom
Does the tub/shower have rubber non-skid mats or strips?
Do you have grab bars (NOT TOWEL BARS) at the shower, tub, and
toilet?
Do you need a bath seat/bench?
Do the rugs have a non-skid backing?
Do you have a hot-water temperature regulator to prevent burns?
Can you get on and off the toilet easily?
Do you need a shower curtain to replace sliding shower doors?
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CRITERIA YES NO N/A

Doorways/Entrance/Exterior
Do all home entrances have outdoor lights?
Are walkways to the doors clear of debris, plants, cracks, and holes?
Are door sills (thresholds) low?
Do outdoor steps have handrails?
Can you clearly see the outline of each step as you ascend & descend the
stairs?
Is a ramp needed?
Do the outdoor steps have a non-skid surface?
Are the outdoor stairs in good repair? (I.e. free from cracks, dips, holes)
Others
Do you have an emergency exit plan (i.e. Fire)?
Are emergency telephone numbers listed near the phone?
Do you have a system to manage medication?
References:
Community & Home Injury Prevention Project for Seniors, San Francisco Dept. of Public Health
Fall Prevention Project, Pima Council on Aging, Tucson AZ
Home Secure, Jewish Family Services of Los Angeles, Los Angeles, CA
Available services for the elderly in KSA
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Short summary about chief health diagnosis
Risk factors
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Atypical manifestations
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Diagnostic tests
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Management
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Geriatric Assessment Sheet

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Kingdom of Saudi Arabia ‫المملكة ال عر بية الس عودية‬

Ministry of Education ‫و زا رة الت علي م‬

GERIATRIC ASSESSMENT SHEET

Part I. Personal Data

Part II. Past Health History

DATE/S REASON/S MEDICAL DIAGNOSIS

Common Illness/Sickness experienced:

Surgeries/Operations (if YES, please fill-out the table below):

Allergies (if YES, please fill out the table):

Part III. Present History

Compliance with Medication: Compliant (yes) noncompliant ( )

Heart Disease: Respiratory Disease:

Part V. Review of Body Systems

Normal Age related Changes Pathological Changes

C. Head and Neck

Lips: Normal: Yes ( yes) No ( )

D. Thorax, Heart, and Lungs

Describe problems related to:

Usual elimination Pattern:

CRITERIA ACTUAL FINDINGS INTERPRETATION

Discomforts during Urination

Part VI. Health Promotion and prevention practice:

D. Routine medical checkup: Yes ( ) No ( )

E. Personal Habits (if applicable only)

1. Cigarette Smoking? Yes ( ) No ( )

Part VII: Falls and Balance evaluation

A. Timed Up and Go (TUG) Test

B. Balance test: Romberg’s test

Part VIII. Functional Status Assessment

2. Instrumental Activities of Daily Living

Part IX. Cognitive Assessment

Part X. Psychological Assessment

Part XI. Social assessment

Part XII: Environmental Assessment

CRITERIA YES NO N/A

Available services for the elderly in KSA

Short summary about chief health diagnosis

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