ATTACHMENT C.

WHO-DOH Short (10-minute) Geriatric Screening Tool

GERIATRIC SCREENING FOR SENIOR CITIZENS

Name: Date (mm/dd/yy)____________________

Last Name First Name MI
Age___ Date of Birth (mm/dd/yy)___________________Gender:______________________ Religion:____________________

Address: _______________________________________________________________________________
No Street Barangay Municipality Province
Name of Accompanying Adult: ___________________________________________ Tel Number:__________________ Relationship to Patient _____________________
Last Name First Name MI

Part 1: Screening Questions Instructions: Ask the screening questions to the patient and check the box (whether YES or NO) indicating their answer.
Yes No Remarks
A1. Memory
Please repeat these 3 objects: Paper, Towel, Cup If YES, the patient is able to recall immediately after you read
Remember the 3 objects because I will ask them again later the 3 objects
B. Depression
Have you experienced feeling of hopelessness or depression for 2 weeks or more? If Yes, counsel and refer to a physician
C.Medications
Are you taking 4 or more medicines and/or supplements? If Yes, refer to a physician if this has potential benefit or risk
of harm.
D. Urinary Incontinence
During the last 3 months, did you leak urine? Any YES indicates signs and symptoms of urinary
1. Even small amount? incontinence. Counsel and refer to a physician.
2. When you cough, sneeze or exercise?
3. When you need to pee but could not go to the toilet?
4. Without sense of urgency or physical activity?
E. Physical Functional Capacity
Are you able to If Yes it means the patient is within normal physical functional
1. Change your clothes without assistance? capacity.
2. Take your bath without assistance? If No, then refer to a physician
3. Eat your meals without assistanc
4. Move around house without assistance?
E. Memory 2
“What were the three objects I asked you to remember?” Refer to BOTH Memory 1 and 2 questions.
If both memory 1 and 2 are Yes, it means the patient can
Ask the patient to complete 3-item recall in item 1. Paper, Towel, Cut recall.
If Memory 1 is Yes and Memory 2 is No OR
Both Memory 1 and 2 are No, counsel and refer to physician.
 F. Fall If Yes, ask:
Have you fallen anytime in the last 12 months? 1. What were you doing before you fell?
2. How did you feel before and after going down?
3. What part of the body was hit?
Counsel and refer to a physician.

Part 2. Screening Tests Instructions: Conduct screening tests and indicate the results
A. Risk for Falls
1. Turned Up and Go Test ______ seconds A score of below 12 seconds is normal
2. Functional Reach Test _______inches A score of more than 8 inches is normal
B. Nutrition
Mid-upper arm circumference (MUAC) measurement ________cm A score less than 22cm may indicate at risk for malnutrition.
A score 22 or greater indicates normal nutritional status of
the elderly
C. Hearing
Whisper Test R ear Check if patient successfully repeats 3 out of 6 number and
L ear letter combinations in the first and second attempts, then it
is considered pass.
Note: if the second attempt is unsuccessful, refer to a
physician
D. Vision
Visual Acuity Test (Snellen Chart) Unaided 20/20 indicates normal vision
R Eye __/___
L Eye __/___ or If Visual Acuity is 20/200 or worse, refer to
Aided: OPHTHALMOLOGIST
R Eye __/__
L Eye __/__
Summary of Findings/Disposition: Screened by: Referred to:
___ Counselled Name and Name and Designation of Provider:
Date of Return Visit ______ Designation of
Provider:
Name and Address of Facility:
____ Referred to a Physician (fill up referred to)
Name and Address of
Date of Referral _______
Facility:
Reason for Referral ________
Telephone Number:
Facility Contact
Details:
_________________________________________________
Signature of Provider:

Notes: