Geriatric Depression Scale (Short Form)

Patient’s Name: Date:

Instructions: 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 following page).

No. Question Answer Score

1. Are you basically satisfied with your life? YES /
2. Have you dropped many of your activities and interests? NO YES /
3. Do you feel that your life is empty? NO YES /
4. Do you often get bored? NO YES /
5. Are you in good spirits most of the time? NO YES /
6. Are you afraid that something bad is going to happen to you? NO YES /
7. Do you feel happy most of the time? NO YES /
8. Do you often feel helpless? NO YES /
9. Do you prefer to stay at home, rather than going out and doing new things? NO YES /
10. Do you feel you have more problems with memory than most people? NO YES /
11. Do you think it is wonderful to be alive? NO YES /
12. Do you feel pretty worthless the way you are now? NO YES /
13. Do you feel full of energy? NO YES /
14. Do you feel that your situation is hopeless? NO YES /
15. Do you think that most people are better off than you are? NO YES /
NO
TOTAL
(Sheikh & Yesavage, 1986)

Scoring:
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.

Sources:
 Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a
shorter version. Clin Gerontol. 1986 June;5(1/2):165-173.
 Yesavage JA. Geriatric Depression Scale. Psychopharmacol Bull. 1988;24(4):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.
Geriatric Depression Scale (Short Form) Self-Rated Version

Patient’s Name: Date:

Instructions: Choose the best answer for how you felt over the past week.

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 new things? YES / NO
10. Do you feel you have more problems with memory than most people? YES / NO
11. Do you think it is wonderful to be alive? YES / NO
12. Do you feel pretty 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
(Sheikh & Yesavage, 1986)
PERSONAL INFORMATION

NAME: AGE/SEX: DOB: DOE:

EDUCATIONAL ATTAINMENT: NO. OF YEARS FORMAL TRAINING:

MINI MENTAL STATE

EXAMINATION FILIPINO
VERSION (MMSE-F)
Validated Filipino Version of Folstein’s
MMSE

Orientation to Maximum Score Response

Score Time: 5 Ano pong
Petsa ngayon? 1 point per correct answer
Ano pong Buwan ngayon?
Ano pong Taon ngayon?
Ano pong Araw ngayon?
Ano pong Panahon ngayon?
Orientation to Maximum Score
Place: 5 Ano pong pangalan ng lugar na ito? 1
point per correct answer Nasaang palapag po tayo ngayon?
Nasaang kalye po ang lugar na ito?
Nasaang siudad/munisipyo tayo ngayon?
Nasaang Bansa po tayo ngayon?
Registration: Maximum Score
(repeated word) 3 Magsasabi po ako ng 3 bagay. Ulitin ninyo ang tatlong
ito pagkatapos
ko sabihin. Tandaan po ninyo ito dahil ipapaulit ko ito
mamaya.
1 point per correct answer MANGGA
MESA
PERA

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
86
79
72
65
If 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
Maximum Score O-D-N-U-M
Recall: 3 Anu-ano po yung tatlong bagay na pinatandaan
ko sa inyo kanina? 1 point per correct answer
 Maximum Score
Language: 9 Ano pong tawag dito? Ituro ang relo
1 point per correct answer ORAL NAMING Ituro ang lapis

REPETITION Ulitin po ninyo ang sasabihin ko: “WALA NANG PERO PERO
PA”
Allow only 1 attempt

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.
Inilagay sa kandungan.
READING
Basahin po ninyo ng tahimik at at gawin ang sinasabi. “IPIKIT MO ANG IYONG MATA”

WRITING
Magsulat po kayo ng kahit anong pangugusap.

COPYI
NG
Kopyahin po ninyo
ito:
DRAW HERE

Total Score/ 30

CLOCK DRAWING TEST

Instruct 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 “sampu makalipas ang alas onse”

DRAW HERE
 Assessed by:

Date Examined:

Adapted from Alzheimer ’s disease Association of the Philippines. Recommendations on the Diagnosis, Prevention and
Treatment of Alzheimer’s Disease, 2005
 Comprehensive Geriatric Screening

This is an interview administered questionnaire. For items nos. 1-37, please supply the information
asked for. (Pagsagot sa talatanungan sa tulong ng tagapanayam. Pakipunan ng tamang mga impormasyon
ang bawat isang tanong mula sa bilang isa hanggang tatlumput-pito.)

1.) Date (Petsa):

2.) File No.:
3.) Interviewer (Tagapanayam):
DEMOGRAPHICS
(DEMOGRAPIYA)

4.) Name (Pangalan): Nickname (Palayaw):

5.) Age in years (Edad): 6.) Sex (Kasarian):  Male (Lalaki)  Female
(Babae)
7.) Address (Tirahan):
8.) Place of birth (Lugar ng Kapanganakan):
9.) Telephone no. (Numero ng telepono): Mobile no. (selfon) :
10.) Civil Status (Katayuang Sibil)
 Single (Walang Asawa)  Widow (Balo)
 Married (May Asawa)  Separated/Divorced (Hiwalay sa Asawa)

11.) Highest Educational Attainment (Pinakamataas na Natapos sa Pag-aaral)

What is your highest educational attainment? (Ano po ang inyong pinakamataas na natapos sa pag-
aaral?)
 Postgraduate (Pagkatapos ng Kolehiyo)  High school level (Hayskul)
 College Graduate (Tapos ng Kolehiyo)  Elementary Graduate (Tapos ng elementarya)
 College Level (Kolehiyo)  Elementary (Elementarya)
 High school graduate (Tapos ng hayskul)

12.) Occupational History

Are you retired? (Kayo po ba ay retirado na?)  Yes (Oo)  No (Hindi)
Note: If the answer is NO, please refer to 12.B.
A. If Yes, what was your previous occupation (Kung retirado na, ano po ang inyong dating trabaho?)

[Link] No, are you currently working? (Kung Hindi, kayo po ba ay nagtatrabaho sa kasulukuyan)?
 Yes (Oo)  No (Hindi)
If Yes, what is your occupation (Kung Oo, ano po ang inyong trabaho)?

13.) List of Financial Resources (Listahan ng Pinansiyal na Pinagkukunan)

Note: Select all that apply.

Where do you get your finances to support your daily expenses?

(Saan po nanggagaling ang inyong pang- araw araw na panggastos)?
 Salary (Sweldo)  Consultancy (Sangguni)
 Pension (Pensiyon):  SSS  Business (Sariling negosyo)
 GSIS
 Foreign
 Others:
 Financial support from (Suportang pinansiyal mula sa): Wife (Asawang babae)
Husband (Asawang lalaki)
Child/Chilldren (Anal/Mga anak)
 Other relatives (Iba pang kamag-anak)
 Others (Iba pa):
14.) Adequacy of Finances
Are your finances enough to support your daily expenses (Sapat ba ang inyong kinikita
upang matustusan ang inyong pang-araw araw na gastos)?  Yes (Oo)  No (Hindi)
Are you worried about your ability to support your healthcare needs (Nangangamba k
aba sa iyong kakayahang suportahan ang inyong pangangailangang pangkalusugan)?  Yes (Oo)
 No (Hindi)

15.) Health Insurance

Do you have a health insurance (Mayroon po ba kayonghealth insurance)?  Yes (Oo)  No
(Hindi)
If Yes, what is it (Kung Oo, ano ito)?  PhilHealth  Other HMOs (Iba pang HMOs):

16.) Living Arrangement (Kalagayan sa Pamumuhay)

Are you (Kayo po ba ay..)  Living alone (Namumuhay mag-isa)
 Living with others (Namumuhay ng may
kasama) With whom (Kasama ang..)? Spouse (Asawa)
 Son/Daughter (Anak)
 Grandchild/children (Apo/Mga Apo)
 Other relatives (Iba pang kamag-anak):
 Others (Iba pa):

17.) Primary caregiver (Pangunahing Tagapag-alaga)

Do you have a primary caregiver (Kayo po ba ay may pangunahing tagapag-alaga)?  Yes (Oo) 
No (Hindi)
If Yes, who is your primary caregiver (Kung meron, sino po ang inyong pangunahing tagapag-
alaga)?

Primary Caregiver’s address:

Telephone No.:

What is your relationship to your primary caregiver (Ano po ang inyong relasyon sa iyong
pangunahing tagapag-alaga)?
 Wife (Asawang babae)  Son (Anak na lalake)
 Husband (Asawang lalake)  Daughter (Anak na babae)
 Son in law (Manugang na lalake)  Grandson (Apong lalake)
 Daughter in law (Manugang na babae)  Granddaughter (Apong babae)
 Professional caregiver (Propesyonal na Tagapag-alaga)  Others:

18.) Housing (Pagpapabahay)

What is the state of your housing (Ano po ang kalagayan ng inyong tirahan o lupa)?
 Owned (Sarili/Pag-aari)
 Rented (Nangungupahan)
 Mortgage (Hulugan)
 Shared renting (Nakikihati sa upa)
 “Nakikitira”
 Others (Iba pa):

SOCIAL

19.) Social Activities (Gawaing Panlipunan)

 Formal (Pormal) YES (Oo) NO (Hindi)
Are you a member of (Kayo po ba ay kasapi ng..)?  
Church groups (Samahan sa simbahan)  
Alumni  
Volunteer group  
 Senior citizen’s organization (Samahan ng mga nakakatanda)  
 Informal
 You are interacting with your.. (Kayo po ay nakikipag-ugnayan o nakikisalamuha sa
inyong..)
 Children (Mga anak)  Sibling/s (Kapatid)  Grandson/daughter (Mga apo)
 Friend/s (Kaibigan)  Neighbor (Kapitbahay)  All of the above (Lahat ng
nabanggit)
 Others (Iba pa):

20.) What is your role in your family? (Ano po ang ginagampanang tungkulin sa inyong pamilya
(halimbawa: tagaluto, tagapag-alaga ng
apo)?

21.) Lifestyle and Self-Care

A. Have you ever smoked (Nakapagsigarilyo na po ba kayo)?  Yes (Oo)  No (Hindi)
Are you a (Kayo po ba ay)?  Current Smoker (Kasalukuyang naninigarilyo)  Previous
Smoker (Dating naninigarilyo): (Kailan pa po kayo huminto sa paninigarilyo?)
If Yes (Kung Oo), since when (kailan pa nagsimula)?
How many sticks per day (Ilang istik/piraso sa isang araw)?

[Link] you ever taken alcohol (Kayo po ba ay nakainom na ng alak)?  Yes (Oo)  No (Hindi)
Are you a (Kayo po bay ay)?  Current drinker (Kasalukuyang umiinom)  Previous
drinker (Dating umiinom): (Kailan pa po kayo huminto sa pag-inom ng alak?)

[Link] you ever taken illicit drugs (Kayo po ba ay nakagamit ka na ba ng ipinagbabawal na gamot)?
 Yes (Oo)  No (Hindi)
Are you a (Kayo po bay ay)?  Current drug user (Kasalukuyang gumagamit ng bawal na gamot)
 Previous drug user (Dating gumagamit ng bawal na gamot): (Kailan pa
po kayo huminto sa pag-gamit ng ipinagbabawal na gamot?)

D. Do you drink coffee (Kayo po ba ay umiinom ng kape)?  Yes (Oo)  No (Hindi)

Are you a (Kayo po bay ay)?  Current drinker (Kasalukuyang umiinom)
 Previous drinker (Dating umiinom): (Kailan pa po kayo huminto sa pag-
inom ng
kape?)

[Link] you drink tea (Kayo po ba ay umiinom ng tsaa)?  Yes (Oo)  No (Hindi)
Are you a (Kayo po bay ay)?  Current drinker (Kasalukuyang umiinom)
 Previous drinker (Dating umiinom) (Kailan pa po kayo huminto sa pag-
inom ng
tsaa?)

Others (Iba pa) (e.g. nganga)

PHYSICAL ACTIVITY (Gawaing Pisikal)

22.) Exercise
Do you exercise (Kayo po ba ay nag-eehersisyo)?  Yes (Oo)  No (Hindi)
What type of exercise do you do (Ano pong uri ng ehersisyo ang ginagawa niyo)?
 Aerobic and endurance Frequency Duration

 Brisk walking
 Running
 Jogging
 Swimming
 Cycling
 Dancing
 Climbing stairs
 Playing sports like tennis, volleyball, soccer, etc
  Others:

 Balance and flexibility Frequency Duration

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

 Strength training
 Weight lifting
 Lunges
 Squats
 Crunches
 Wall push ups
 Others:

23.) Leisure
Do you engage in leisure activities (Kayo po ba ay may ginagawa sa mga pagkakataong
may libreng panahon)?  Yes (Oo)  No (Hindi)
If Yes, please specify your leisure activity/ies (Kung Oo, pakitukoy):

24.) Hobbies
Do you have a hobby (Kayo po ba ay mayroong libangan)?  Yes (Oo)  No (Hindi)
If Yes, please specify you hobby/ies (Kung Oo, pakitukoy):

HEALTH (KALUSUGAN)

25.) History of Fall

In the past 3 months, have you experienced fall? (Sa nakaraang tatlong buwan, kayo po ba ay
nakaranas na ng pagkadapa, pagkahulog,o pagkatapilok?)  Yes (Oo)  No (Hindi)
Circumstances surrounding the fall (Ano po ang kalagayan o mga bagay bagay na naging
sanhi ng inyong pagkahulog):
Did you seek medical treatment after the fall (Kayo po ba ay kumunsulta sa manggagamot
matapos mahulog)?  Yes (Oo)  No (Hindi)
Post fall consequences (Resulta ng Pagkahulog) Yes (Oo) No (Hindi)
Loss of Consciousness (Kayo po ba ay nawalan ng malay?)  
Physical Injury (Pisikal na pinsala tulad ng?)  
Sprain (Pilay)  
Fracture (Pagkabali sa buto)  
Others (Iba pa):

Fear of Falling
Are you afraid of falling (Natatakot po ba kayong mahulog o madapa)?  Yes (Oo)  No (Hindi)

26.) Consultation with Healthcare provider

Kayo po ba ay nagpapatingin sa tagapagbigay ng pangangalagang pangkalusugan?  Yes (Oo)  No
(Hindi)
If Yes, to whom (Kung Oo, kanino)?
27.) Medical Illness/ Problem List (List of Acute and Chronic Illness, Allergies, etc.)
Sa inyong pagkakaalam, anu-ano po ang inyong mga sakit ayon sa inyong doktor?

Medical Date Date Resolved Course of

Illness Started (Petsa ng Action
(Sakit) (Petsa ng Pagresolba) (Mga ginawang
Pagsisimula) Year (Taon) aksyon)
Year
(Taon)

28.) Medication History (Including prescription, non-prescription, herbal, and nutritional supplements)
Are you taking any medication within the past two weeks (Kayo po ba ay umiinom ng gamot
nitong nakaraang dalawang lingo?)  Yes (Oo)  No (Hindi)

If Yes, what is/are it/these? (Kung Oo, anu-ano po ang mga ito)?
Medications Dosage Frequency

Herbal medicines
Nutritional supplements

29. Alternative Therapies

 Acupuncture
 Chelation
 Others:

30.) Immunizations
Have you ever been vaccinated as an adult (Kayo po ba ay nabakunahan na ngayong nagka-edad
na)?
 Yes (Oo)  No (Hindi)
If Yes, what is/are it/these (Anu-ano po ang mga ito)?
Date of Immunization Year
(Taon)
Influenza 
Pneumococcal 
Tetanus 
Chicken Pox 
Hepatitis B 
Herpes zoster 
Others (Iba pa): 

31.) Family Medical History

(Anu-ano po ang mga sakit sa inyong pamilya?)
 Tuberculosis (Tuberkulosis)  Asthma (Hika)
 Coronary Artery Disease (Sakit sa puso)  Hypertension (Altapresyon)
 Cerebrovascular disease (Istrok)  Dementia ex. Alzheimer’s disease
 Cancer (Kanser)
 Diabetes Mellitus (Diyabetis)  Others:

32.) For women only: (Para sa mga kababaihan lamang)

Age at menopause (Ano po ang inyong edad ng huminto ang inyong regla):
Menopause (Paghinto ng regla) Natural (natural)  Surgical (operasyon)
HRT use (Kayo po ba ay gumamit ng hormone therapy):  Yes (Oo)  No (Hindi)
Previous use of OCP (Kayo po ba ay gumamit ng kontraseptibo)?  Yes (Oo)  No
(Hindi) Kayo po ba ay nakapagpa-Pap smear na?  Yes (Oo)  No
(Hindi) If Yes (Kung Oo), results (ano po ang resulta):
Kayo po ba ay nakapagpa-Mammogram na?  Yes (Oo)  No (Hindi)
If Yes (Kung Oo), results (ano po ang resulta):
Kayo po ba ay nagpasuri sa buto tulad ng Dexa Screening?  Yes (Oo)  No (Hindi)
 Peripheral  Central T score

33.) Past Surgical Procedures

Have you ever undergone surgery/operation? (Kayo po ba ay ma mga napagdaanan ng mga
operasyon)?
 Yes (Oo)  No (Hindi)
If Yes, what is/are it/these (Kung Oo, anu-ano po ang mga ito?)

Surgical Procedures Year (Taon)

34.) Self-Rated Health (Q#1): (Pansariling Pananaw sa Kalidad ng Buhay)
How would you rate your current state of health (Paano niyo ituturing ang pangkasalukuyang
estado ng iyong kalusugan)?
[1] [2] [3] [4] [5]
Poor Fair Good Very good Excellent
(Mahina) (Katamtaman) (Mabuti) (Mabuting-mabuti) (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 nakalipas na buwan, kayo po ba ay
nagkaroon ng problema sa pagtulog tulad ng hirap sa agad na pagtulog, madalas na paggising sa
pagtulog, o maagang paggising sa umaga)?  Yes (Oo)  No (Hindi)

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 nakaramdam ng pagkalungkot, pagkalumbay, o kawalan
ng pag-asa sa buhay)?
 Yes (Oo)  No (Hindi)
* If Yes, proceed to GDS

37.) REVIEW OF SYTEMS

Considering the past 3 months, select all that apply and write details if applicable. Sa nakalipas na
tatlong buwan, kayo po ba ay nakaranas ng…

General
 Weight Gain (Pagbigat ng timbang) □□□□kg  Weight Loss (Pagbaba ng timbang) □□□□ kg
 No weight changes (Walang pagbabago sa timbang)  Fever (Lagnat)
 Fatigue (Pagod)  Loss of appetite (Walang ganang kumain)
 Others (Iba pa):

Gastrointestinal
 Dental Carries (Dental karis o may sira ang ngipin)  Pain (Kirot)
 Dentures (may pustiso)  Constipation (Nagtitibi)
 Edentulous (wala ng ngipin)  Diarrhea (Nagtatae)
 Loss of taste (Walang lasa sa pagkain)  Incontinence (Hindi mapigilan and pagdumi)
 Dysphagia (Hirap na paglunok o nasasamid)  Melena (May bahid ng dugo ang dumi)
 Odynophagia (Masakit ang paglunok)  Hematochezia (May dugo sa dumi)
 Vomiting(Pagsusuka)  Hemorrhoids (Almoranas)
 Hematemesis (Pagsuka ng dugo)  Others (Iba pa):
 Nausea (Naduduwal)

Pulmonary
 Cough (Ubo)  Shortness of breath (Hingal)
 Difficulty Breathing (Hirap sa paghinga)  Others (Iba pa):

Genitourinary
 Dysuria (Hapdi o sakit sa pag-ihi)  Dribbling (Paunti-unting pag-ihi)
 Frequency (Madalas umihi)  Nocturia (Madalas magising sa gabi para umiihi)
 Bleeding (May pagdurugo)  Others (Iba pa):
 Incontinence (Hindi mapigilan ang pag-ihi)
Sexual
You may choose not to answer the following questions on sexual activity (Maaring hindi ninyo po
sagutan ang mga sumusunod na tanong tungkol sa pagtatalik).
For men: Are you sexually active (Kayo po ba ay aktibo pa sa pakikipagtalik)?  Yes (Oo)  No (Hindi)
Do you have problems with erection (Mayroon po bang problema sa pagtigas ng ari)?
 Yes (Oo)  No (Hindi)
Do you engage in safe sex (Kayo po ba ay nakikipagtalik ng may pag-iingat)?  Yes (Oo)  No
(Hindi)
If Yes, what do you use (Kung Oo, ano po ang inyong ginagamit)?

For women: Are you sexually active (Kayo po ba ay aktibo pa sa pakikipagtalik)?  Yes (Oo)  No
(Hindi)
Do you have problems with sexual intercourse (Mayroon po bang problema tuwing
nakikipagtalik)?
 Yes (Oo)  No (Hindi)
Do you feel any pain during the intercourse (Nakakaramdam po ba kayo ng sakit tuwing
nakikipagtalik)?
 Yes (Oo)  No (Hindi)
Do you engage in safe sex (Kayo po ba ay nakikipagtalik ng may pag-iingat)?  Yes (Oo)  No
(Hindi)
If Yes, what do you use (Kung Oo, ano po ang inyong ginagamit)?

Gynecologic
 Discharge (Lumalabas sa pwerta)  Prolapse (Prolaps o buwa)
 Bleeding (May pagdurugo)  Others (Iba pa: )
 Pruritus (Pangangati)

Psychiatric
 Confusion (Nagugulumihanan)  Anxiety (Kaba o nerbiyos)
 Memory Loss (Pagkalimot) * If Yes, proceed to MMSE  Agitation (Pagkataranta)
 Wandering (Pagala-gala o napunta sa ibang lugar ng hindi alam kung papaano makabalik)
 Depression (Nakakramdam ng kalungkutan)  Paranoia (Lubos na paghihinala)

Neurologic
 Syncope (Nawalan ng malay)  Numbness (Pamamanhid)
 Tremors (Nanginginig)  Bradykinesia (Mabagal na paggalaw)
 Paralysis (Naparalisa)  “Pasma”, describe (ilarawan)
 “Nangangalay”, describe (ilarawan)
Vision
(Ang inyong mga mata po ba ay..)
 Blurred (Malabo, maulap, o mausok)
Using Vision aid:  Yes (Oo)  No (Hindi) Type:  Eyeglasses (Salamin)  Contact lens  Both
(Pareho)
 Floaters (Bagay na palutang-lutang sa paningin)  Tearing (Nagluluha)
 Blind Spots (Mayroong parte na hindi makita)  Redness (Namumula)
 Photopsia (mga gumuguhit na ilaw)  Glare (nasisilaw)
 Eye pain or heaviness (Masakit o mabigat sa pakiramdam)  Itchy (Nangangati)
 Foreign body sensation (pakiramdam na may nakapuwing sa mata)

Ears and Hearing

 Hearing problem (Kayo po ba ay may problema sa pandinig)  Yes (Oo)  No (Hindi)
 Use of hearing aid (Kayo po ba ay gumagamit ng tulong pandinig)?  Yes (Oo)  No (Hindi)
 Tinnitus (Tinitus o may umuugong sa tenga)  Ear pain (Masakit ang tenga)
 Ear discharge (May lumalabas sa tenga)  Itchiness (Pangangati)
 Others (Iba pa)

Balance
 Dizziness (nahihilo)  Vertigo (naliliyo o umiikot ka o ang paligid)
 Imbalance or disequilibrium (parang natutumba o diniduyan)
Cardiac
 Palpitations (nakakaramdam ng palpitasyon)  Chest Pain (Pananakit ng dibdib)
 Dyspnea (nahihirapan sa paghinga)  Easy fatigability (Madaling mapagod)
 Orthopnea (Ortopniya o parang nalulunod sa tuwing nakahiga)  Pedal Edema (Namamanas ang
paa)
 Others, (Iba pa)

Speech/Language
 Slurred (Nabubulol)
 Dysarthria (Hirap sa pagsasalita)  Others (Iba pa)

Musculoskeletal
 “Artritis”:  Muscle wasting/atrophy (nangunguluntoy ang kalamnan)
 “Rayuma”:  Muscle tone/stiffness (Naninigas ang mga kalamnan)
 Musculoskeletal pain (Sakit sa buto o kalamnan):  Joint pain: Neck Back
Hip Other site:

Activities of Daily Living (ADL)

Physical ADLs Instrumental ADLs
1 0
1 0
Bathing (Pagligo) Using the telephone (Paggamit ng
telepono)
Dressing (Pagbihis) Shopping (Pamimili)
Toileting (Pagbanyo) Food preparation (Paghanda ng pagkain)
Housekeeping (Pag-ayos o paglinis sa
Transfers (Pagbangon) bahay)
Laundry (Paglalaba)
Continence
(Pagpigil sa ihi o Transportation (Pagsakay)
dumi) Taking medicine (Pag-inom ng gamot)
Feeding (Pagkain)
Managing money (Pangangalaga ng pera)
ADL Score IADL Score

Physical Examination

BP (mmHg): Standing: Sitting: HR (bpm): RR:

Height (cm): Weight (kg): BMI (kg/m2): *Proceed to MNA-SF if BMI is <18.5 or >23

Hip circumference (cm): Waist circumference (cm): WH Ratio:

Demi span (cm): R L
General:
Pain  Yes (Oo)  No (Hindi)

Location
 VISUAL ANALOG SCALE (VAS)

0 10
NO PAIN SEVERE PAIN
HEENT:
Vision Hearing
Visual acuity:
Gross examination: Rinne’s test:
Weber’s test:
Otoscopic exam:

Chest/Lung

s:

Heart/CVS:

Abdomen:

Spine and Extremities:

Neurological Examination

A. Mental Status Examination

1. General behavior and appearance:  Normal  Hyperactive  Agitated  Quiet  Immobile

 Neat  Slovenly
Do clothes match the patient’s age, peers, sex, background? Y
N
2. Stream of thought: Does the patient converse normally? Y N Repetitive? Y N
3. Speech: Rapid Incessant Under great pressure Lack spontaneity and prosody
4. Language: Is the patient discursive, tangential, and unable to reach the conversational goal?
Y N
5. Mood and affective responses: Euphoric Agitated Giggling Silent
Weeping Angry Is the mood appropriate? Y N
Is the patient emotionally labile? Y N
6. Content of thought: Illusions Hallucinations Delusions Misinterpretations
Does the patient suffer delusions of persecution and surveillance by malicious persons or forces?
Y N
Is the patient preoccupied with bodily complaints, fears of cancer or heart disease, or other
phobias?
Y N
7. Intellectual capacity: Bright Average Dull Obviously demented  Mentally retarded
8. Sensorium: Consciousness:
Attention span:
Orientation for time, place, and person:
Memory (recent and remote):
Fund of information:
Insight, judgement, and planning:
Calculation:
[Link] Nerves
Normal (-) Abnormal (+)

I
 II. Fundus

Visual

Fields

Visual

Acuity

III, IV, VI
V VII VIII IX, X XII

[Link] muscle testing D. Motor Exam

Grading (0-5)
Muscle strength:
Muscle group R L Extrapyramidal:
Muscle atrophy/hypertrophy:
neck flexors Muscle tone:  Spastic  Rigid  Flaccid
 Passive movement of the joint
 Slowness and reduce
shoulder abductors spontaneity

shoulder adductors Endurance: 

Fatigability
elbow flexors
Presence of spontaneous movements:
 Fasciculation  Tremors
elbow extensors

wrist flexors
E. Reflexes
wrist extensors

grip

hip flexors hip

extensors knee

flexors
knee extensors

foot dorsiflexors

foot plantarflexors

Remarks:

F. Sensation
NormalAbnormalFindings G. Coordination and Gait

Light touch

Pain/temperature
Joint
position/vibratory

Findings NormalAbnormal

Posture

Functional reach

Time up and go test

Cerebellar signs

Summary of Findings
Signature over Printed Name

MD Signature over
Printed Name
Mini Nutritional Assessment
MNA®

Last name: First name:

Sex: Age: Weight, kg: Height, cm: Date:

Complete the screen by filling in the boxes with the appropriate numbers. Total the numbers for the final
screening score.
Screening
Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?
0 = severe decrease in food intake
1 = moderate decrease in food intake 2 = no decrease in food intake

Weight loss during the last 3 months

0 = weight loss greater than 3 kg (6.6 lbs) 1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs) 3 = no weight loss

Mobility
0 = bed or chair bound
1 = able to get out of bed / chair but does not go out 2 = goes out

Has suffered psychological stress or acute disease in the past 3 months?

0 = yes2 = no

Neuropsychological problems
0 = severe dementia or depression 1 = mild dementia
2 = no psychological problems

F1 Body Mass Index (BMI) (weight in kg) / (height in m)2

0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater

IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION

F2. DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY
COMPLETED.
F2 Calf circumference (CC) in cm
0 = CC less than 31
3 = CC 31 or greater

Screening score
(max. 14 points)
Save
12-14 points: Normal nutritional status Print
8-11 points: At risk of malnutrition
Reset
0-7 points: Malnourished

Ref. Vellas B, Villars H, Abellan G, et al. Overview of the MNA® - Its History and Challenges. J Nutr Health Aging 2006;10:456-465.
Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for Undernutrition in Geriatric Practice: Developing the Short-Form Mini Nutritional Assessment (MNA-SF).
J. Geront 2001;56A: M366-377.
Guigoz Y. The Mini-Nutritional Assessment (MNA®) Review of the Literature - What does it tell us? J Nutr Health Aging 2006; 10:466-487. Kaiser MJ, Bauer JM, Ramsch C,
et al. Validation of the Mini Nutritional Assessment Short-Form (MNA®-SF): A practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13:782-788.
® Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners
© Nestlé, 1994, Revision 2009. N67200 12/99 10M

For more information: [Link]