COR JESU COLLEGE, INC.

COLLEGE OF HEALTH SCIENCES

Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC PATIENT PROFILE

Name: _______________________________________
Age: _______________________________________
Date of Birth: _______________________________________
Sex: _______________________________________
Occupation: _______________________________________
Address: _______________________________________
Civil Status: _______________________________________
Number of Children: _______________________________________
Spouse Name:
_______________________________________
Occupation:
_______________________________________
Mother’s Name: _______________________________________
Occupation: _______________________________________
Address: _______________________________________
Father’s Name:
_______________________________________
Occupation: _______________________________________
Please provide documentary evidence (photos during interview, with
Address: _______________________________________
date stamp on the photo, photo with the interviewer and interviewee.
Religion: _______________________________________
May also provide video evidence of interview.

Page 1 of 7
 COR JESU COLLEGE, INC.
COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC NURSING ASSESSMENT

ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
I. MENTAL STATUS
A. STATE OF MENTAL
CONCIOUSNESS
B. ORIENTATION
C. INTELLECTUAL CAPACITY
D. VOCABULARY LEVEL
E. ATTENTION SPAN
F. ABILITY TO UNDERSTAND

II. STATUS OF SPATIAL SENSES

A. AUDITORY PROBLEM
B. VISUAL PROBLEM
C. SPEECH PERCEPTION
D. TACTILE PERCEPTION
E. OLFACTORY PERCEPTION
Submitted By: Submitted to:

_______________________________________________________ ______________________________________________________

COR JESUPage
COLLEGE,
2 of 7 INC.
COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph
 GERIATRIC NURSING ASSESSMENT
ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
III. MOTOR ABILITY
A. CURRENT MOBILITY
B. POSTURE
C. RANGE OF JOINT MOTION
D. MUSCLE AND NERVE STATUS
E. LOSS OF EXTREMITIES

Submitted By: Submitted to:

_______________________________________________________ ______________________________________________________

Page 3 of 7
 COR JESU COLLEGE, INC.
COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph

GERIATRIC NURSING ASSESSMENT

ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
IV. BODY TEMPERATURE
A. RANGES

V. RESPIRATORY STATUS
A. CHARACTER
B. USE OF RESPIRATORY AIDS
C. INTERFACES WITH
RESPIRATIONS
D. ABNORMAL RESPIRATORY
OPENING
VI. CIRCULATORY STATUS
A. CHARACTERISTIC OF ARTERIAL
PULSE
B. BLOOD PRESSURE
C. APICAL-RADIAL PULSE
D. INTRAVENOUS FLUIDS

Submitted By: Submitted to:

_______________________________________________________ ______________________________________________________

COR JESUPage
COLLEGE,
4 of 7 INC.
COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph
 GERIATRIC NURSING ASSESSMENT
ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
VII. NUTRITIONAL STATUS
A. CONDITION OF BUCCAL
ACTIVITY
B. DIGESTION FOODS

VIII. ELIMINATIONS STATUS

A. BOWEL
B. BLADDER
C. ABNORMALITIES

IX. MALE REPRODUCTIVE STATUS

A. PROSTATE GLAND

X. FEMALE REPRODUCTIVE STATUS

A. AGE OF MENARCHE
B. PREGNANCY
C. VAGINA
D. CERVIX
E. VAGINAL DISCHARGE
F. VAGINAL BLEEDING
G. LAST MENSTRUAL PERIOD (LMP)

COR JESU COLLEGE, INC.

COLLEGE OF HEALTH
Page 5 of 7 SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of
Davao Del Sur
Website: www.cjc.edu.ph
 GERIATRIC NURSING ASSESSMENT
ONGOING ASSESSMENT
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
XII. STATE OF SKIN AND APPENDAGES
A. SKIN
B. HAIR
C. NAILS

XIII. STATE OF PHYSICAL ARREST AND COMFORT

A. SLEEP/REST PATTERN
B. PRESENCE OF
PAIN/DISCOMFORT
C. USE OF SUPPORTIVE AIDS

XIV. EMOTIONAL STATUS

A. EMOTIONAL REACTIONS
B. BODY IMAGE
C. ABILITY TO RELATE OTHERS

XIV. NURSING DIAGNOSES

Submitted By: Submitted to:

_______________________________________________________ ______________________________________________________

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CENTRAL NERVOUS SYSTEM
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_______________________________________
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RESPIRATORY SYSTEM
_______________________________________
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MUSCULO-SKELETAL SYSTEM
_______________________________________
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REPRODUCTIVE SYSTEM
_______________________________________
_______________________________________
_______________________________________
_______________________________________
________________
GERIATRIC INITIAL ASSESSMENT
OTHER SIGNIFICANT DATA OBTAINED
___________________________________________________________________
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GASTRO-INTESTINAL SYSTEM
_______________________________________
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GENITO-URINARY SYSTEM
_______________________________________
_______________________________________
_______________________________________
_______________________________________
________________
CIRCULATORY SYSTEM
_______________________________________
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_______________________________________
________________
INTEGUMENTARY SYSTEM
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