GERIATRIC CLIENT PROFILING TOOL

Demographic Data

Name:
Address:
Age:
Date of Birth:
Sex:
Civil Status:
Religion:
Educational Attainment:
Employment Status:

Family and Social Profile

Support Person/s:
Living Condition:
Usual Meals:
Daily Pattern:
Hobbies:
Sleeping Pattern:
Caffeine Intake:
Alcohol Intake:
Smoking Pattern:
Recreational Drug Use:

Health History

Present Illness:

History of Past Illness/es and/or Hospitalization/s:

Birth Problems: None

Childhood Illnesses: None
Adult Illnesses:
Accidents: None
Allergies: None

Medications History

Prescribed Medications: None

OTC Drugs: None
Herbal: None
Immunization/s:

History of Family Illness

Cardiovascular Diseases: None

Renal: None
Cognitive Impairments: None
Blood Disorders: None
Other: None

Cognitive Assessment SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ) Version 1

Ask the client with following questions:

1. Today’s Date
2. Day
3. Client’s Address
4. Phone Number
5. Age
6. Current President of the Country
TOTAL

Functionality Assessment (KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING)

Can the client perform the following routine/activities:

1. Bathing
2. Dressing
3. Toileting
4. Transferring
5. Continence
6. Feeding
TOTAL

Instrumental Activities of Daily Living Scale (Lawton-Brody)

1. Ability to use Telephone

2. Shopping
3. Food Preparations
4. Housekeeping
5. Laundry
6. Transportation
7. Handle medications
8. Handle Finances
TOTAL

Psychological Assessment

No. Question Answer Score

1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO

3. Do you feel that your life is empty? YES / NO

4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
 9. Do you prefer to stay at home, rather than going out and doing YES / NO
new things?
10. Do you feel you have more problems with memory than most? YES / NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel worthless the way you are now? YES / NO
13. Do you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
TOTAL
Score 1 point for each bolded answer (highlighted red). A score of 5 or more suggests depression

This is the original scoring for the scale: One point for each of these answers. Cutoff: normal-0-9; mild depressives-10-19; severe
depressives-20-30.

Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report.
J Psychiatr Res 1983; 17:37-49.