Developed by the lnstitute on Aging-NlH UP Manila, Philippine College of Geriatric Medlcine.

and NCGH DOH

Comprehensive Geriatric Screening

This is an interview administered questionnaire. For items nos. 1-37, please supply the information asked for,
{Pogsagot sq tolqtonungan so tulong nE tagoponoysm. Pakipunon ng tomong mga impormqsyon ang bowot isong
tanong mula sa bilang isa honggang totlumput-pito.)

1.) Date 0f /30/aorn

2,) File No.:
3.) lnterviewer (Tagapanayam):
DEMOGRAPHTCS {D EM OG RAP tYA)

4.) Name {Pangolon): Errn 0. ?orttC (rq{9!l Nickname (Paloyaw): Yrrn: tt

5.) Age in years (Edad): 6. Sex (Kasorian): E Male {Laloki)t Female (Bobae)
7.) Address (Tirahon):
8.) Place of birth (Lugar ng Kapangonakon):
9.) Telephone no. (Numero ng telepono): no. (selfon) : _
10.) Civil Status (Katayuang Sibil)
I Single (Wolang Asawo] tr Widow /8olo)
E Manried (May Asowo) u Separated/Divorced (Hiwolay sa Asowo)

11.) Highest Educational Attainment {Pinakomataas na Natapos sa pag-aaral}

What is your highest educational attainment? (Ano po ang inyong pinakamstods ns ndtopos sa pag-aarot?)
EI Postgraduate (Pagkatapos ng Kolehiyo) il High school level {Hayskul)
fCollege Graduate (Tapos ng Kolehiyo) E Elementary Graduate (Topos ng elementorya)
E College Level (Kolehiyo) E Elementary {Etementarya)
tr High school graduate (Tapos ng hoyskut)

12.) Occupational History

Are you retired? {Kayo po ba ay retirado na?) I
Yes {Ooj D No (Hindi)
Note: lf the answer is NO, pleose refer to 12.8.
A" lf Yes, what was your prevrous occupation {Kung retirado no, qno pa ang inyong dating trabaho?)

B. lf No, are you currently working? (Kung Hindi, kayo po ba oy nogtotrabaho so kosulukuyan)?
il Yes /Oo) frNo {Hindi)
lf Yes, what is your occupation (Kung Oo, ano po ang inyonE trabaho)?

13.) tist of Financial Resources (Listahon ng Pinansiyol no Pinogkukunan)

Note: Select all that apply.
Where do you get your finances to support your daily expenses?
(Saan po nonggagoling ang inyonE pong- orow oraw na panggastos)?
il Salary {sweldo) [ Consultan cy {sangguni)
tl Pension (Pensiyon): O 555 f, Business (sariling negosyo)
o GSIS
O Foreign
O Others:
[1 Financial support lrom {suportang pinonsiyol mula so/; OWife {Asawang babae)
-0Husband (Asowa ng lo la ki)
OChild/Chill dren (Ana l/M ga a n a k)
OOther relatives (lbo pang komag-anok)
fl Others (lbo pa):

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Developed by the Institute on Aging-NlH UP Manila, Phllippine College of Geriatric Medicine, and NCGH DOH

14.) Adequacy of Finances

Are your finances enough to support your daily expenses (5opat ba ong inyong kinikita upsng motustusan
ong inyong pong-araw arow na gastos)?.f Yes (Oo) Z No {Hindi)
Are you worried about your ability to support your healthcare needs (Nangangambo k aba sa iyong
kakoyahong suportohon ong inyong pongangailongang pangkalusugon)? ilYes (Oo) a No @indi)

15.) Flealth lnsurance

Do you have a health insurance (Mayroon po ba kayongheolth insuronce)? [ Yes {Oo,l } No (Hindi)
lf Yes, what isit {Kung Oo, ono ito)? D PhilHealth E Other HMOs ltba pang HMOs):

16.) Living Arrangement (Kalagoyan sa Pomumuhoy)

Are you (Kayo po ba oy..) E Living alone (Namumuhay mog-isa)
_
ll tiving with others (Nomumuhay ng mqy kasoma)
With whom {Kasama ong..)?O Spouse (Asawa)
O Son/Daughter {Anok)
C Grandchild/children (Apo/M ga Apo)

E Others (lba pa)

17.) Prinnary caregiver {Pangunohing Tagopog-olago)

Do you have a primary caregiver (Kayo po ba oy may pongunohing tagapog-alagal? E Yes (Oo) fr No (Hindi)
lf Yes, who is your primary caregiver (Kung meron, sino po ang inyong pangunahing togopag-atogo)?

Primary Caregive/s address:

Telephone No.t

What is your relationship to your primary caregiver (Ano po ong inyong relosyon sa iyong pangunahing
togapag-aiago)?
E Wife (Asawang baboe) [ Son (Anak na lotake)
E Husband (Asawong lalake) E Daughter (Anak na bqbae)
fl Son in law {Manugong na laloke) fl Grandson (Apong lolake)
[1 Daughter inlaw {Manugong na boboe) fl Granddaughter (Apong bqbae)
D Professional caregiver {propesyonal na Tagapog-atoga) D Others:

18.) Housing ( Pagpa pa bahay)

what is the state of your housing (Ano po ong kalogayan ng inyong tirahqn a lupa)?
. E Owned (sorili/Pag-aori)
E Rented (Nangungupoho n)
E Mortgage (Hulugan)
E Shared renting (Nakikihati sa upo)
il "Nakikitira"
I Others (tba pq):

soclAr

19.) Social Activities (Gawaing Panlipunan)

-E Formal (Pormal) YES (Oo) No {Hindi}
Are you a member of (Koyo po ba ay kasapi ng..)? tr n
Church groups {Samahon so simbahan) ,d u
Alumni
Volunteer group
-rtr n
n
Senior citizen's organization (Somohan ng mgs nakakotanda) { tr
fl lnformal
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You are interacting with your.. (Kayo po oy nokikipag-ugnqyqn o nskikisalamuha sa inyong..)

O Children {Mgo anak) O Sibling/s (Kapatid) O Grandson/daughter (tvtga apo}
O Friend/s {Kaibigan) O Neighbor {Kapitbahay) O Allof the above (Lahat ng nabanggit)
O Others (lba pa):

20.) What is your" role in your family? {Ano po ong ginagompanqng tungkulin so inyong pomilya (halimbawo:
t0galuto, ng
(o uattetY.

21.) lifestyle and Self-Care

A. Have you ever smoked (Nokapagsigarilyo na po bc kayo)? n Yes [Ool D No {Hindi)
Are you a {Koyo po ba ay)? [ Current Smoker (Kosalukuyang naninigarilyol I Previous Smoker {Dating
naninigarilyo): (Kailon pa po koyo huminto so paninigarilyo ?
}fYes{Kungoo}sincewhen{koilonponagsimulo)?-
How many sticks per day (llong istik/piraso so isong orow)?

B. Have you ever taken alcohol (Kayo po bo ay nokoinom na ng olak)? D Yes (Ool lE fuo {Hindi)
Are you a lKayo po boy ay)? D Current drinker (Kasolukuyang umiinom) n Previous drinker (Doting
umiinom): {Koilon po po kayo huminto sa pag-inom ng olqk?)

C. Have you ever taken illicit drugs (Koyo po ba ay nakagamit ko na bo ng ipinagbabawal no gomot)?
D Yes 10o) G *o luinail
Are you a lKoyo po bay ay)? O Current drug user (Kasalukuyang gumagamit ng bawal no gamot)
il Previous drug user (Dating gumogqmit ng bowal na gamat): (Kailon pa po kayo
humintosapag-gamitngipinagbabawalnagamot?)-
D. Do you drink coffee (Kayo po ba ay umiinom ng kope)? I Yes /Oo.) D No {Hindi)
J Current drinker (Kosolukuyang umiinom)
Are you a lKayo po bay ay)?
! Previous drinker (Dating umiinom): (Kailon pa po kayo huminto so pag-inom ng
kope7,) ?mr:rr,iunfi * lmrffin Iarq

E. Do you drink tea (Kayo po ba ay umiinam ng tsoa)? I Yes /Ool n No Hindi)

Are you a lKayo po bay ay)? I Current drinker lKasalukuyang umiinom)
E Previous drinker (Doting umiinom) (Koilan pa po kayo huminto so pog-inom ng
tssa

Others (lba pa) _ (e.g. nganga)

PHYSICAL ACTIYITY {Gawoing Pisikal)

22.) Exercise
Do you exercise {Kayo po ba ay nag-eehersisyo)? f Yes (Ool fr xo luinai)
What type of exercise do you do (Ano pong uri ng ehersisyo ang ?
I Aerobic and endurance Frequency Duration

-0 Brisk walking s- '( trttrl,'tgl

5 *i rurle^s
e Running -i rni llvl(l .( - i( ,^rnvWt
O Jogging
O Swimming
3 Cycling
e Dancing
J *vrinVtc.f 5* i:C *oi,rtrrl&J
-rf uni Yru\tcs .f - iif unr,nUi|g.f
G Climbing stairs
.5 nriftr,t(r S- l.( *r,n,.,Lo,
O Playing sports like tennis, volleyball, soccer, etc
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O Others:

fl Balance and flexibility Frequency Duration

O Yoga
O Taichi
O Pilates
O Basic (Static) stretches

f Strength training
O Weightlifting
O Lunges
O Squats
O Crunches
l{}Iallpush ups 6urinr]{l}-J' {* iL utr s, u rt.l
O Others;

23.) teisure
Do you engage in leisure activities (Koyo po ba oy may ginagawa so mga pagkakataong moy libreng
panahan)? E Yes (OoJ J no TUinail
lf Yes, please specify your leisure activity/ies (Kung Oo, pakitukoy): nen.!ig siJplo, *dl, *hiS(,
24.) Hobbies
Do you have a hobby {Koyo po ba ay mayroong iibongon)? TYes (Oo) n No lHindri
lfYes,pleasespecifyyouhobby/ies(KungOo,pokitukovl: $rrrtri'rn+ gr t;{ctct11,y5
Jr Iior.tC $. i,JUr,Slrr i

HEAIJH {KALUSUGAN)

25.) History of Fall

ln the past 3 months, have you experienced fall? (5o nakaraong totlong buwan, kayo po ba ay nokoronos no
ng pogkadapa, pagkahulog,o pagkotopilok?) [J Yes lOoJ A No pindil
Circumstances surrounding the fall iAno pa ang kolagoyon o mga bagay baEay na naging sanhi ng inyong
pagkahulog)
Did you seek medical treatment after the fall (Koyo po ba oy kumunsulta sa monggagomot motopos
mahulog)? fl Yes (0ol D No {Hindi)
Post fall consequences (Resulta ng Pogkahulog) Yes @o) No (Hindi)
Loss of Consciousness (Koyo po ba ay nowalan ng malayT) n n
Physical lnjury {Pisikal na pinsala tulad ng?) n tr
Sprain (Pilay) tl tr
Fracture (Pogkabali so buto) n n
Others (lba pa):

Fear of Falling
Are you afraid of falling (Notatakot po ba koyong mahulog o madapa)? t Yes iOoJ frNo (Hindi)

25.) Consultation with Healthcare provider

Kaya po bo ay nagpapatingin sa tagapagblgay ng pangongalogong pangkalusugan?.AYes {Oo) ilNo fifindi)
lf Yes, to whom (Kung Oo, konlnol? N rJ r'S 0 0Ltt-,i, rr
/

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Developed by the lnstitute on Aging-NlH UP Manila, Philippine College of Geriatric Medicine, and NCGH DOH

27.) Medical lllness/ Problem list (List of Acute and Chronic lllness, Allergies, etc.]
Sa inyang pogkakaalom, onu-ono po ang inyong mgo sakit ayon sa inyong doktor?

Medical lllness Date Started Date Resoived Course of Action

(Sakit) {Petsa ng Pagsisimula) (Petso ng Pagresolba} {Mga ginowang oksyon)
Year(Taon) Year {Taon)

U 0n gning Tslv$iaor*"n
{") rdi be,ti u i"cic _* ofl nntn(
Jt)vgrg Gr,{h (t
U trrl-h\al lc,l.C '.l,rne' LILO i tfi,itlr
PrucAf hcn

28.| Medication Histcry (lncluding presription, non-prescription, herhal, and nutritional supplements)
Are you taking any medication within the past two weeks {Kayo po ba ay umiinom ng gomot nitong nakaraang
dalawang lingo?) dnYes fool tr Uo {g;na,
rf what dnu-ono ?
Medications Dosage Frequency

$ - coup\eie 5o o wrj
2,v d*Y
lns,,rli n tI tr
/ ,^t"I,,1{utlrfi\f,q )
,Lrtq[cUqr,,t<r]
)x }, crl
q6 ti,rrtscrritci.rl I t llt t L ^,A
d1

Herbal medicines

Nutritional supplements
-t

Iru,tf ^'1a ..1.!

tt

r, l{ i

t l li l
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Developed by the lnstitute on Aging-NlH UP Manila, Philippine College of Geriatric Medicine, and NCGH DOH
29. Alternative Therapies
E Acupuncture
E chelation
fl others:

30.) lmmunizations
Have you ever been vaccinated as an adult {Kayo po bo ay nabokunohon na ngsyong nagko-edad na)?
tr Yes [ool ANa Hindi]
lf Yes, what is/are it/these (Anu-ano po ang mga ito)?
Date of lmmunization Year
(Taon)
lnfluenza trEEtr
Pneumococcal ntrtrtr
Tetanus trtrtrtr
Chicken Pox iltrtrtr
Hepatitis B trftnil
Herpes zoster ntrtrn
Others (lba pa): ntrtrtr
31.) Famity Medical History
(Anu-ano po ong mga sokit sa inyong pamilya?)
ITuberculosis {Tuberkulosis) D Asthma /Hrko,l
il puso) I
Coronary Artery Disease (Sakit sa Hypertension {Aitapresyon)
il $strok)
Cerebrovascular disease fl Dementia q4 Alzheimels disease
fl Cancer {Konser)
lDiabetesMellitus (Diyabetis) EOthers: [I,i r rciJt Irdr,.i:r-p;f.r.srsiilnri th*{ rt'rvtt
-ic lu.ii Ci c.uir.sc.rJur,[ 11g..l:t.
32.) For women only: {Pora so mga kaboboihan lamong)
Age at menopause (Ana po ang inyong edad ng huminto ong inyang reglg: E A
Menopause (Paghinta ng regla) f
Natural {natural) tr Surgical {operasyon}
HRT use (Kayo po ba ay gumamit ng hormone therapy): tr Yes fool .A No fiindi)
Previous use of OCP {Kayo po ba oy gumamit ng kontraseptibo}? D Yes 1,Ool frN;o (Hindi)
Kaya po ba ay nokopagpa-Pap smear na? E Yes lOol DNo (Hindi)
lf Yes (Kung Oo), results {ano po ang resulta): t ttttr Ngg dtl'vC
f -
Kayo po ba ay nakapagpa-Mammogram na? n Yes lool tr ruo fHina,
lf Yes (Kung Oo,l, results (ano po ang resulta):
Kaya po ba ay nagpasuri sa buto tulad ng Dexa Screening? tr Yes {oo,} ANo {Uinai)
E Peripheral fl Central Tscore_

33.| Past Surgical Procedures

Haveyoueverundergonesurgery/op€ration? (Kayopobaay ma mga nopagdaandn ng mgaoperasyon)?
tr Yes (0oJ .I No (Hindi)
lf Yes, what is/are i{these {Kung Ao, anu-ono po ang mga ito?)

Surgical Procedures Year (Taon)

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34.) Self-Rated Health lQ#tl:_(Pansoriling Panonow sa Kolidod ng Euhay)

How would You rate your current state of health (Paano niyo ituturing ong pongkasolukuyang estado ng iyong
kalusugan)?
t1l t21 .*5f t4l tsl
Poor Fair Good Very good Excellent
{Mahina} {Katamtamsn) (Mobuti) (Mabuting-rnabuti) (Napakabuti)

35.) Sleep
Overall, in the past month, have you experience problems with sleeping such as falling asleep, waking up
frequently during the night or waking up early (Sa nokolipos na buwan, kaya po ba ay nogkaroon ng problema
sd pagtulog tulqd ng hirap sa agad na pagtulog, mcdalas na paggising sa pagtulog, o masgang paggising so
umaga)? - f Yes {Ool n No lH,nd,

36.! Depression
During the past month, have you been bothered by feeling down, depressed or hopeless (Sa nakalipas na
isang buwan, kayo po ba ay nakaromdam ng pogkalungkot, pogkalumbay, o kawolan ng pog-oso so buhay)?
I Yes /ooJ ANo {Hindi)

37.) REVTEW OF SYTEMS

Considering the past 3 months, select all that apply and write details if applicable. Sa nokalipas na totlong buwon,
kayo po ba ay nakaranss n9...

General
tr weight Gain (Pagbigat ng timbongJ lnrnkg E Weight Loss (Pogbqbo ng timbangl nli:r kg
E No weight changes (Walang pagbabogo sa timbang) E Fever (Lagnat)
E Fatigue (Pagod) fl Loss of appetite {Watang ganang kumain)
E Others {lba pa):

Gastrointestinal
fl Dental Carries (Dentol koris o moy sira ang ngipin) I Pain {KrorJ
il Dentures lmay pustiso) E Constipati an {Nagtitibi)
fi Edentulous {wala ng ngipin) E Diarrhea (Nagtatae)
EI Loss of taste (Wolang loso sa pagkain) E lncontinence (Hindi mapigilan and pagdumi)
D Dysphagia {Hirap na poglunok o nososamid) fl Melena {May bahid ng dugo ong dumi)
E Odynophagia (Mosokit ang poglunok) fl Hematochezia {May dugo sa durni}
D Vomitingf Pogsusuko) fl Hemorrhoids {Al m oro nas)
f] Hematemesis {Pagsuko ng dugo) E Others (lba pa): :, ii,t
E Nausea {Naduduwol)

Pulmonary
tr Cough {Ubol fl Shortness of breath {Hingat}
fl oifficulty Breathing {Hirap sa paghinga) t others f/bo pal: I l-cilrf tii c; ii',- ihf Ctul
Genitourlnary
EI Oysuria (Hapdi o sakit sa pag-ihi) tr Oribbling {Pounti-u nting pag-ihi)
I irequency {Madalas umihi} tr Nocturia (Madalas magising sa gabi para umiihi)
[1 Bleeding (May pagdurugo) Il Others (lba pa): _
E lncontinence (Hindimapigilan ang pag-ihi)
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Sexual
You rnay choose not to answer the following questions on sexual activity {Maaring hindi ninyo po saguton ang mga
sumusunod na tsnong tungkol sa pagtatalik).
For men: Are you sexually actiue {Koyo po ba oy oktibo pa so pokikipogtalik)? DYes (Ao) il No (Hindi)
Do you have problems with erection (Moyroon po bang problema sa pagtigos ng ari)?
tr Yes iool DNa {Hindi}
Do you engage in safe sex (Kayo po ba ay nakikipogtalik ng may pog-iingot)? tr Yes /Ool fr No (Hindi)
lfYes,whatdoyouuse(Kungoo,anopoonginyongginagomit)?

For women: Are you sexually active {Kayo po ba oy aktibo pa so pakikipagtalik)? tr Yes (Oa) ) Na {Hindi)
Do you have problems with sexual intercource {Mayroon po bang problema tuwing nakikipagtalik)?
[lYes (ool ,JNo luinag
Do you feel any pain during the intercourse {Nakakaramdam pa ba kayo ng sakit tuwing rrqkikipagtatik)?
tr Yes /ool fiNo(Hindi)
Do you engage in safe sex (Kayo po bo ay nskikipagtalik ng may pog-iingat)?Il Yes fool 3 No (Hindi)
lf Yes, what do you use {Kung aa, ano po ang inyong ginagamit)?

Gynecologic
fl Discharge (Lumolobas so pwerto) E Prolapse (Pralaps o buwa)
E Bleeding (May pagdurugo) E others (tbo pa:
E Pruritus {Pangangati)

Psychiatric
fl Confusion (Nagugulumihanan) flAnxiety {Kaba a nerbiyas)
H Memory (Pagkalimot)
l,oss fl Agitation (pogkatoranta)
il Wandering (Pagala-gala o nopunta so ibang lugor ng hindi alam kung papaono mokabalik)
il Depression {Nakokramdam ng kalungkutan} E Paranoia (Lubos na poghihinala)

Neurologic
U Syncope (Nawalan ng molay) E Numbness (Pamamanhid)
E Tremors (Nonginginigl tm, 1 3) EI Bradykinesia (Mabogal na paggalaw)
il Paralysis (Naparaliso) fJ "Pasma", describe (ilarawon) _
I "Nangangalay", describe (ilorawanl nrl _g,r
p,1J y,rrru1r.
Vision
(Ang inyong mga motl po ba ay.")
I Blurred {Malabo, moulop, o mausok)
Using Vision aid: IYes (CId ANo fiindi) Type:-I Eyeglasses (salamin) El Contact lens EI Bath (pareha)
EI Floaters {Bagay no palutanglutang sa paningin) ElTearing (Nagtutuha)
I Blind Spots (Mayraong porte na hindi makita) E Redness (Namumula)
.f Photopsia {mga gumuguhit na ilaw} Jclare (nasisilaw)
fl Eye pain or heaviness lMasokit o mabigat sa pakiramdam) E ttchy (Nangangati)
n Foreign body sensatian(pakiramdam na may nakapuwing sa mata)

Ears and Hearing

fl Hearing problem (Kayo po ba ay moy problemo sa pondinig) tr yes lool il no @inai1
fl use of hearing aid {Kayo pa ba ay gumagamit ng tulong pandinig)? flYes (ool E ruo fruina,
fl Tinnitus (Tinitus a may umuugong sa tenga) [*] Ear pain {Masakit ang tenga)
[f Ear discharge (May lumalabas sa tenga) E ttchiness (Pangongati)
fI Others (tbo po)

Balance
E Dizziness {nahihilo) [1 ve*igo (natitiyo a umiikot ka o ang paligid)
E lmbalance or disequilibrium (porong natutumba o diniduyan)
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Cardiac
f, Palpitations (nakakaramdam ng palpitosyonJE Chest Pain {Panonakit ng dibdib)
I Dyspnea (nohihiropan sa poghinga) I Easy fatigability {Madotinq mapagod)
fl O*hopnea (Ortopniys o parlng nalulunad ss tuwing nakohigo) D pedal Edema {Namamanas ang pao}
fl Others, {lba pa) _
Speech/Language
E Slurred (Nsbubulal)
E Dysarthria (Hirap sa pagsasalita) t,
E Others (lbo pa)

Musculoskeletal
E "Artritis": N< t ve frt,i:\r t( E Muscle wastinglatrophy (nongunguluntoy dng kalamnan)
E"Rayurna", ffi
!'Muscle tonelstiffness {Noninigas aflg mga kalamnan)
! Musculoskeletal pain fsokit so buto o kalamnan): O Joint pain: _ Neck _ sack 1lUip *Other site: *-_
Activities of Daily Living (ADl-)
ADLs lnstrumental ADLs
L 0
1 0

Bathing {Pogligo} Using the telephone (Paggamit ng

i I
telepono)
Dressing (Pagbihis) Shopping (Pamimili) I
I
Food preparation (Poghanda ng pagkain) I
Toileting {Pagbonyo}
l Housekeeping (Pag-ayos o paglinis sa
I
Transfers (Pogbongan) bahoy)
I
taundry Paglotaba) I
Continence (Pogpigil so 4\ Transportati on { Pagsakay)
I
ihi o dumi) U
Taking medicine {Pog-inom ng gamot) I
Feeding (Pagkain)
I Managing money (Pangangalaga ng pero)
I
ADL Score
5 t lADt Score
8 c
Physical fxamination

Bp (mmHg): standing: trr; f fq sifting: "!i!liu HR {bpm}: {u -- RR: lu

Height (cmh 5 ' i weight (ke): ,5j!q BMI (kglm2), )J.L if BMI is <18.5 or >23
Hip circumference {cm): }t Waist circumference (cml: 7.1 WH Ratio: (} 8.t (.H:testqt f:..!)
Demi span (cm): R J 1 .-., _L J.L csn
General:
Pain EYes{Ool flNo{Hindi)

Location

vrsuAl ANALOG SCALE {VASI

| .,a

0 10
NO PAIN STVERE PAIN

I
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HEENT:
Vision Hearing
Visualacuity: 'bono 1oo1}*d{,r-yt.
Rinne's test:
€ross examination: Weber's test: r za.+iorr "

A, Mental Status Examination

1. General behavior and appearance: *ltormal E Hyperactive E Agitated E Quiet E lmmobile

fi Neat [3 Slovenly
Do clothes match the patient's age, peers, sex, background?ff EU
2. stream of thought:. Does the patient converse normallyr Jv
Etlu Repetitive? Ev fx
3. Speech:'flRapiddlncessant ilUndergreat pressure EILack spontaneity and prosody
4. Language: ls the patient discursive, tangentiat, and unable to reach the conversational goal? trY EIil
5. Mood and affective responses:.trEuphoric gAgitated trEiggling Elsilent llllueeplng EAngry
ls the mood appropriate? trN ly
ls the patient emotionally labile? Ey EN
6. Content of thought: Elllusions [JHallucinations EDelusions EMisinterpretations
Does the patient suffer delusions of persecution and surveillance by malicious persons or forces?
trY trN
ls the patient preoccupied with bodily complaints, fears of cancer or heart disease, or other phobias?
trY ON
7. lntellectual capacity: EAright demented EI Mentally retarded
8. Sensorium: Consciousness:
Attention span:
Orientation for time, and person:
Memory (recent and remote!:
Fund of information:
lnsight, judgement, and
Calculation:
B. Cranial Nerves
Normal{-} Abnormal{+}

I itu vt,c^tl is 'll't(

otrri-\-(r\tJ
tt
A' i<rrltlu. ivt
I LLI.J(( Y vrnl,aitn
ll. Fundus Lr, d'Lc, ilglil rLitrx I
uir rl[ w\\ur\ ttuul f\ rl)t.tt
VisualFields
"Iht l+ $err thc
",l,t j
Stianvl,
.lty $t,ty I \eg tl.
VisualAcuity "rh0 d't$t h*rl0 a
[0p
Vr.ri0n ra\4r3 oy- 3O//0.
lll, lv, vl ftCre ii &itt ci rec\elturi
of ?uf:\ .a, nr trrc,turt cu.!
10
Subject to copyright 2015
 the lnstitute on lH UP Ma Ph of Geriatric and NCGH DOH
\l I h(/ o"'d.s i aI{{ i.t { { t"nnip-
trr i$tl .1 ga r'tli.r6,]ir,tg' 6r:.1
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ID 15
1s1g6r1-
xfi The p{, r,rtqs cr.blg hirh"k
aJll-{irq\lg trr.* on layWal
r[r ir"
C. Manual muscle testing D. Motor Exam

Grading {0-5) Muscle strength: Lc

rl,'r

Muscle group R Extrapyramidal: aL.

L
Muscle atrophylhypertrophy: t*r
neck flexors
5 Muscle tone; E Spastic fl Rigid tr
-.- E Passive movement of the ioint
shoulder abductors .\ ,r spontaneity
E Slowness and reduce

shoulder adductors
J r Endurance: Can cn&,iu&
Fatigability
+q^,,1 E
elbow flexors
s r Presence of spontaneous moyements:
E Fasciculation I Tremors
elbow extensors
,J r \r
wrist flexors
.\ r\ E. Reflexes
wrist extensors
T 5
grip
s 5
hip flexors r/-r (
\- 5 5 sl'r 's sl,r
hip extensors
s 'Y sls
knee flexors
._s rr s
a

knee extensors
s \r iss
foot dorsiflexors C
'.f
foot plantarflexors
.,9 9 /.f
.t ls vts
Remarks:
'1v"{
e il

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Subject to copyright 2015
 Developed by the lnstitute on Aging-NlH UP Manila, Philippine College of Geriatric Medicine, and NCGH DOH

F. Sensation
Normal Abnormal Findings G. Coordination and Gait
Findirgs Normal Abnormal
light touch
Posture
Pain/temperature
Functional reach
Joint /
positionlvibratory Time up and go test

Cerebellar signs

Summary of Findlngs

Itlh,\o txeh,\ininq *he ,1,*t,shs k abte aYrl, No\'^ Ctne\Auinq hu dSLor bl

s],e <litl manage $ {ru'co& -fhv *cs-!r',} !9,.q -!q{:*qta {*14t !- 100 Ss*qTafL: I*{
(tu *u5 errtd'rtnto 'tnns^orq
{o's't an}

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v
&qre\ifton ' t} tq'wrrqo\
T'lT.#f;f,#r.ffifl,
E

"OWLL
Signature over Printed Name

hcv
MAo csl.sTlt\t a. oh?
Signature over Printed Name

lZ
Subject to copyright 2015
 Geriatric Depression Scale (Short Form)

Patient's Name: f r wi,i ?.t.t 0.(t, o.tdtl Date: ,trJ'go lao 2o

lnstrugtions: 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 foltowing page).

No. Question Answer Score

1 Are you basically satisfied with your life? vaglNo i
2 Have you dropped many of your activities and interests? yEsl No I

3 Do you feel that your life is empty? Yes t xd L

4. Do you often get bored? Yesl l*d ,a)
l-/
E
Are you in good spirits most of the time? Y{s I No i
I

6 Are you afraid that something bad is going to happen to you? YEs I D*d i
7 Do you feel happy most of the time? ,ffr No 7,
8. Do you often feel helpless? Yesl-lto 7
I Do you prefer to stay at home, rather than going out and doing new things? .ytsf,l No 1

10. Do you feelyou have more problerns with memory than most people? Yesl-U6
11. Do you think it is wonderfulto be alive? yffilNo .J,

12. Do you feel pretty worthless the way you are now? _YESI No t,
13 Do you feel futl of energy? J#tNo 1

14. Do you feelthat your situation is hopeless? YEs/No i

'15. Do you think that most people are better off than you are? vEs/ bkr t-,

TOTAL LU
& Yesavage, 1

Scorina:
Answers indicating depression are in bold and italicized; score one point for each one selected. A score of 0 to 5
is normal A score greater than 5 suggests depression.

Sourcesi
. Sheikh Jl. Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter
version. Clin Gerontal. 1986 June;5(1/2):165-173.
. Yesavage JA. Geriatric Depression Scale. PsychopharmacalBull.lg$s;24(a).709-711.
. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale:
a preliminary report. J Psychiatr Res. 1982-83;17(1):37-49.
!1

Geriatric Depression Scale (Short Form)

Self-Rated Version

Patient's Name: Lr*na ?aA,o Date: Auq . JD, *rO2D

I,nstructions.' Choose fhe best answer for how you felt over the past week.

No. Question Answer Score

1 Are you basically satisfied with your life? Yjdl No
2 Have you dropped many of your activities and interests? Yes / No i
3 Do you feelthat your life is empty? - YES / b}d L

yEs l
4. Do you often get bored? uxf o
5. Are you in good spirits most of the time? ydrNo t

6. Are you afraid that something bad is going to happen to you? vrs I utd L
7 Do you feel happy most of the time? Ytgl No t
8. Do you often feel helpless? YES /NO L
g Do you prefer to stay at home, rather than going out and doing new things? YeJNo
10. Do you feelyou have more problems with memory than most people? vd No I

11. Do you think it is wonderfulto be alive? v6r ruo &

12. Do you feel pretty worthless the way you are now? Y.r8'l N0 I
13 Do you feelfull of energy? YFs'l No \
14. Do you feelthat your situation is hopeless? Yes I Nef &
-l
15. Do you think that most people are better off than you are? YES /r(5 d-

TOTAL 1n
6d-
},

Page 1 of 2

PERSONAL INFCIRMATION

NAME: E,rwr ?aA,io A6E/sEX: oIL DoB: &rli1J3I500r: ,I u vr ( .J Q , 119 ,

EDUcAfioNAL ATrAtNMerur: L u \lt
3
lGfsUL No. oF yEARs FoRMAL TRAINING: _ \ grlaf
MINI MENTAL STATE EXAMINATION
FTLTPTNO VERSTON (MMSE-F)
Vslidoted Fitipina Version of Folstein's MMSE

Orientation to Maximum Score Score

Time: 5 Ano pong Petsa ngayon?
1 point per correct answer Ano pong Buwan ngayon?
Ano pong Taon ngayon?
Ano pong Araw ngayon? 1

Ano pong Panahon o "Season" I

Orientation to Maximum Score
Place: 5 Ano pong pangalan ng lugar na ito? I i
1 point per correct answer Nasaang palapag po tayo ngayon? I

Nasaang kalye po ang lugar na ito?

Nasaang siudadlmunisipyo tayo I
Nasaang Bansa po tayo ngayon? 1
Registratlon: Maximum Score
(repeated word) 3 Magsasabi po ako ng 3 bagay. Ulitin ninyo ang tationg ito pagkatapos
ko sabihin. Tandaan po ninyo ito dahil ipapaulit ko ito mamaya.
X point per corect answer MANGGA 1

MESA
PERA
-t.*
Maximum Score
Attention 5 Pwede po ba kayong magsimula sa 100 at magbilang ng paatras
habang nagbabawas ng 7 sa bawat pagkakataon?
100 bawasan ng 7, ilan poi yon?

CORRECT ANSWER GIVEN ANSWER

93 Eb
tiu l
86
(q
_ Ir
79 _l
72 +*_ l
65
-0
lf the patient cannot or will not peform this task, ask the patient to spell the WORLD or MUNDO backwards

Baybayin o paki-spell po ninyo ang salitang "MUNDO"pabaligtad

O-D.N.U-M
Maximum Srore
Recall: 3 Anu-ano po bagay na pinatandaan ko sa inyo kanina?
1 point per correct answer t
0
U
]

Page 2 of 2

Maximum Score
Language: 9 A,no pong tawag dito? Ituroang' -l' Pl'ur't
L'r-tl
cott?[r.i.it
1 point per correct answer ORAL NAMING Ituro ans lapis lAt rS
-{-.--l-_-
REPETITION Ulitin po ninyo ang sasabihin ko: "WALA, NANG PERO PERO PA"
Atlow only j" ottempt {

OBEYING ORAL COMMANDS

Gawin po ninyo ang sasabihin ko.

Kunin po ninyo ang papel gamit ang inyong kanang kamay.
Tiklupin ito sa gitna at ilagay sa iyong kandungan.

Kinuha ang papel gamit ang tamang kamay. \

Tiniklop sa gitna ang papel. l
lnilagay sa kandungan. t
READING
Basahin po ninyo ng tahimik at at gawin ang sinasabi. "lplKlT MO ANG IYONG MATA"

WRITING
Magsulat po kayo ng kahit anong pangugusap. it

COPYING
Kopyahin po ninyo ito

DRAW HERE

.1,

Total Scorel 30
e8
CLOCK DRAWING TEST

lnstruct the patient to draw a clock; starting with the circle look like the face of a clock and then draw the hands of the clock to read
"10 after 11" or "sanrpu makalipas ang alas onse"

DRAW HERE

li
tL

Z LO q
{
t;
\
7
)
3
q
? t, s
Assessed Ma! (cir l-,-cur & Qtr-
ovr c.\?cLv1

Date rxamineo: ffrQ ?D, &DZl)

Adapted from Alzheimer k disease lsso ciation of the Philippines. Recammendat:ions on the Diagnosis, Prevention and
7'reatment of Alzheitner's Disease, ZAAS