I.
PERSONAL PROFILE
1. Personal Data
Name:Lucresia Agbigay Acob
Age: 65 years old
Date of birth: September 26, 1957
Civil Status: Married
Place of Birth: City of Batac, Ilocos Norte
Highest Educational attainment: College Graduate
Occupation: Retired
Religion: Roman Catholic
Address: Brgy. Nalupta, City f Batac, Ilocos Norte
Client’s Impairment: Stroke and spinal (adda crack na kase nabitugak) diagnosed
_______Diagnosed
Undiagnosed
Chief Complaint:
1. F
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fi
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F
A
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Family Age Sex Civil Rel. w/ the Educational Religion Occupation Residence
Members Status px attainment
Lorven Acob M Married Spouse College Catholic Mechanic Brgy. 12, Laoag
Graduate City, Ilocos
Norte
Lawrence A. F Married Daughter College Catholic College
Eclarin Graduate Instructor
Lairesse A. F Married Daughter College Catholic Non-working
Otico Graduate
Lei-Anne A. F Married Daughter College Catholic OFW
Dela Cruz Graduate
2. Occupational Profile
Occupational History:
Retired? / Yes No
If yes, what was the previous occupation? self-employed what???
If No, is client currently working?
Yes No If Yes, what is the
occupation?
List of Financial Resources:
Where does the client get finances to support his/her daily expenses?
Salary
Pension
SSS
GSIS
Foreign
Others: Pls specify
Consultancy
Own business (Pls specify)
Financial support
Spouse
Children
Grandchildren
Other Relatives (Please Specify)
Others (Please specify)
Adequacy of Financial Resources:
Are finances enough to support client’s daily expenses?
Yes No
Is client worried about his/her ability to support his/her own health care needs?
Yes No
With Health Insurance? Yes
PhilHealth
Other HMOs Please specify:
No
Living Arrangements:
Living alone
Living with other
Spouse
Son
Daughter
Grandchild/children
Other Relatives (Please specify)
Others (Please specify)
With Primary Caregiver? / Yes No
Who is the Primary Caregiver?
Relationship to the primary caregiver:
State of Client’s Housing:
/ Owned
Shared renting
Rented
“Nakikitira”
Mortgage
Others:
SOCIOECONOMIC BACKGROUND
Table 1. Family’s Monthly Estimated Net Income
Name of Family Occupation Place of Work Estimated Net Income
Members
Lorven Acob
Lawrence A. Eclarin
Lairesse A. Otico
Lei-Anne A. Dela Cruz
Lorven Acob
TOTA
L
Table 2. General Itemized Expenses
Expenses Amount
1500
Wet Market
500
Dry Market
Grocery 3000
2500
Medications
Business
400
Drinking Water
500
Water Bill
7000
Electric Bill
800
Gasul (LPG)
Miscellaneous
1300
Communication
500
Transportation
DONT WANT TO DISCLOSE
Savings
TOTAL
3. Environmental Profile
Type of housing:
Number of people living: 4
Degree of privacy: each household member has each own room
Describe nearest neighbor:
4. Recreation or Leisure profile
Hobby and interest:
1. browsing the internet
2.
Organizational membership
1. senior citizen
2.
3.
4.
5.
Degree of vacation or travel:
5. Resources/support system being used
sss,philhealth,
II. HEALTH HISTORY
a. Family Health History
FIRST Name Age/Death Cause of Medications/Interventions
GENERATION Age Death/Prevailing
Disease
1.
Paternal Side
2.
Maternal Side 1.
2.
SECOND Name Age/Death Cause of Medications/Interventions
GENERATION Age Death/Prevailing
Disease
Paternal Side 1.
2.
3.
4.
5.
Maternal Side 1.
2.
3.
4.
5.
THIRD Name Age/Death Cause of Medications/Interventions
GENERATION Age Death/Prevailing
Disease
1.
2.
3.
4.
5.
6.
7.
III. ASSESSMENT USING THE GERIATRIC
ASSESSMENT TOOLS a. Barthel Index of
Activities of Daily Living
Bowels
0 = Incontinent (or needs to
be given enema) 1 =
occasional accident
(once/week)
2 = continent
Patient’s Score:
Bladder
0 = incontinent, or catheterized and
unable to manage 1 = occasional
accident (max. once per 24 hours)
2 = continent (for over 7 days)
Patient’s Score:
Grooming
0 = needs help with personal care
1 = independent face/hair/teeth/shaving (implements provided)
Patient’s Score:
Toilet use
0 = dependent
1 = needs some help, but can do
something alone 2 =
independent (on and off,
dressing, wiping) Patient’s
Score:
Feeding
0 = unable
1 = needs help cutting,
spreading butter, etc. 2 =
independent (food provided
within reach) Patient’s
Score:
Transfer
0 = unable – no sitting balance
1 = major help (one or two people,
physical), can sit 2 = minor help
(verbal or physical)
3 = independent
Patient’s Score:
Mobility
0 = immobile
1 = wheelchair independent, including corners, etc.
2 = walks with help of one person
(verbal or physical) 3 = independent
(but may use any aid)
Patient’s Score:
Dressing
0 = dependent
1 = needs help, but can do about half unaided
2 = independent (including buttons, zips, laces etc)
Patient’s Score:
Stairs
0 = unable
1 = needs help (verbal,
physical, carrying aid) 2 =
independent up and down
Patient’s Score:
Bathing
0 = dependent
1 = independent (or in shower)
Patient’s Score:
Total Score:
Psychological Assessment of the Elderly
Questions Yes Justification
or No
1. Able to manage retirement
years in a satisfying manner?
2. Participates in social and
leisure activities?
3. Have a social network of
friends and support persons?
4. View life as worthwhile?
5. Have a high self- esteem?
6. Gain support from the value system and/or spiritual philosophy?
7. Accept and can adjust the death of significant others?
MNA
A. 1
B. 2
C. 0
D. 0
E. 2
F. height = 5’2 weight = 141 pounds
G. 1
H. 0
I. 1
J. 2
K. yes, yes, yes
L. 1
M. 1
N. makapangan ngem maiblend = 1
O. 1
P. 0
Q.
