Universidad de Manila

College of Health Sciences

Geriatric Nursing
I. Personal Data College Undergraduate
Name: College Graduate
Age: Vocational
55-60 65-70 75-80 No Formal Education

85-90 95 and above Can you read?

YES NO
Gender:
Male Female V. Emotional Patterns
What type of mood are you usually in?
Nationality: Calm Pleasant Others

Civil Status: How do you express yourself during a mood

change?
Widow Married Single Separated Verbally Non Verbally

Religion: Does your relation with others change with

your mood?
II. Pattern of Functioning YES NO
Who are the people significant to you?
Family Friends Siblings Relatives VI. Socio- Cultural Health
Recreational activities
Who do you talk to on a regular basis? Watching TV
Family Friends Siblings Relatives Listening to radio
Drink Alcohol
Do you have anyone to go to in times of Read Books/Newspaper
trouble? Board Games
YES NO Run Around
None
Do you exercise regularly?
YES NO
VII. Environment
How do you handle stressful situations? What type of dwelling do you live in?
A. Physical Single Multiple
Eat Sleep Drink Alcohol Exercise
Are you comfortable where you live?
YES NO
B. Psychological
Solve Problems Accept Deny Do you have enough space for yourself?
YES NO
C. Social
Talk with person involved Blame others Do you difficulty walking around your place?
YES NO
D. Others:
_______________________________________ Are there sounds, noises, odors that concern
_______________________________________ you?
_______________________________________ Sound noise odor none
_______________________________________

VIII. Activities of Daily living

III. Interaction Patterns Nutrition:
How do you express your feelings and Food Preference
thoughts? Meat Vegetable Mixed Fish
Verbally Non Verbally
Food Preparation
How do you feel about the way you interact? Fried Stew Smoked Raw
Satisfied Happy Sad Not Satisfied
How many times do you eat in a day?
IV. Cognitive Patterns 1-2 3-4 4-5 more than 5
What is your highest educational attainment?
Elementary Undergraduate Do you have difficulty in eating?
Elementary Graduate YES NO
HS Undergraduate
HS Graduate
Do you avoid certain food? IX: Health Status
YES, Specify:________ NO A. Presence of any illness
(Specify)___________________________
How many glasses of fluid do you take in a day?
2-3 4-6 6-8 more than8 B. Height:

Hygiene: C. Weight:
How often do you brush you teeth in a day?
1x 2x 3x Every other day D. VS
BP
How often do you trim your nails in a week? RR
1x 2x PR
Temp
Do you use cologne, deodorant, perfumes?
YES NO
Last Clinical Check up
Are you able to attend to your personal self Within the week
care needs? Two weeks ago
YES NO Last Month
3 months ago
Rest and Sleep: 5 months ago
How many hours of sleep do you have in a day? A year ago
2-3 4-6 6-8 more than8 Never

Do you take naps?

YES, how many hours/minutes?_____ NO Last Hospitalization
Within the week
Do you have difficulty getting sleep? Two weeks ago
YES NO Last Month
3 months ago
Exercise: 5 months ago
Do you exercise regularly? A year ago
YES NO Never

How many times in a week do you exercise?

1-2x more than 2

What form of exercise?

Walking Stretching Running Aerobics

Elimination:
How many times do you void/urinate in a day?
3-4 5-7 6-8 more than8

Do you have difficulty voiding?

YES NO

How many times do you defecate a day?

once twice thrice

Do you have difficulty defecating?

YES NO

Source of Money
Family
Pension
Work
Friends/Relatives