MSWD Form Republic of the Philippines

No. 5 City of Manila

MSWD Assessment Tool

for Elderly

Date of Interview Time of Interview Basic Ward / Service Non-Basic Ward Health Record No. MSWD No.
(Specify) (Specify) Pay

SOURCE OF REFERRAL Address Contact No.

NAME:
Informant/Caregiver Relation to Patient Contact No. Address of Informant

I. DEMOGRAPHIC DATA
Patient Name: Surname First Name Middle Name

Date of Birth Age Sex O Male O Female

Contact No. Place of Birth Gender O Male O Female O LGBTQIA+ Optional
Religion Nationality
Permanent Address Temporary Address

Civil Status (Check) O Single OMarried O Common Law O Widowed O Separated ( _ Legally, _ in Fact)

O Primary OSecondary O Vocational Occupation

Highest Educational O Tertiary O Post Graduate Patient's Monthly Income
Attainment
O No Educational Attainment PhilHealth Identification PhilHealth Membership (Check)
Number (PIN) O Direct Contributor
O Indirect Contributor

Family Composition
Relationship to Educational
Name Age Date Birth Civil Status Patient Attainment Occupation Monthly Income

Other Sources of Income: Household size Total Household income: Per Capita Income:

II. MSWD CLASSIFICATION

O Artisanal Fisher folk
O Financially Capable/Capacitated O Farmer and Landless Rural Worker
Membership
Main Classification O Financially Incapable/Incapacitated O O Urban Poor
Indigent to
O Indigenous Peoples
Marginalized O Senior Citizen
Sub Classification Sector
O Formal Labor and Migrant Workers
for Non Phil Health (Check)
O Workers in Informal Sector
covered O C1 O C2 O C3 O PWD
admission/ O Victims of Disaster and Calamity
procedures O Others:
III. MONTHLY EXPENSES
Particulars Estimated Particulars Estimated Light Source Fuel Source Water Source (Check)
Monthly Cost Monthly (Check and (Check)
(Php) Cost state amount)
(Php)
House & Lot Communication O Electric O Gas Artesian Well

Food & Water House Help O Public

O Kerosene O Firewood
Education Medical Expenses O Private
O Water District
Clothing Others: Specify
O Candle O Charcoal
Transportation

TOTAL
IV. MEDICAL HISTORY
Reason for Referral Primary Care Physician
When was their last visit? Admitting Diagnosis
Final Diagnosis (Upon Discharge) Prognosis
Duration of Problems/Symptoms Previous Treatment/Duration
Medications Health Accessibility Problem
Present Treatment Plan
Are there any barriers to receiving health care? How well do they seem to understand their medical
conditions?
In the past 6 months, how many times have you:
Fallen Sought ER Been Placed in a Skilled Nursing Sought Mental Health
care Hospitalized Facility care
A. Family Situation
1.What kind of family support do they have?
What are the strengths and challenges of their support system
2. Are they married/widowed?
If they’re married what is their spouses health like/limitations
3. How many children if any do they have? Where do they live what is their relationship like?
Do they have grandchildren or great grandchildren?
4. What are their relationships like with their family
It may be helpful to do a genogram to understand family history and dynamics
5. What is their emergency contact information?
B. Other Support Systems
1. What kind of friend network do they have?Phone calls, visits, outings?
2. Are there any community or religious supports?
3. Have there been any recent losses? People, pets, jobs, abilities/functioning, etc.
C. Caregiver Assessment
1. Primary caregiver
2. Age of caregiver
3. Relationship to patient
4. Physical health of caregiver
5. Number of days/hours a week providing care
6. What type of care is provided
7. Other responsibilities of caregiver (employment, children, other)
• How does caregiver view responsibilities – overwhelming, stressful, etc.
• Has patient displayed disruptive behaviors?
• Can caregiver physically and emotionally manage patient’s needs?
• Are there tasks that the caregiver is uncomfortable doing or physically cannot manage
• What is the caregiver’s appearance/attitude?
D. Living Situation
1. Type of Living  Owned  Shared  Rent  Homeless  Institutionalized
Arrangement
2. Who do they live with?
3. What is their home set up? Do they have stairs they have to navigate?
4. Are they able to get around their home independently?
5. Do they use medical equipment to navigate their home?
6. Are they independent in their Activities of Daily Living (ADL)?
7. If they live alone do they have someone to check on them regularly?
8. Are they safe in their home?
E. Home Safety (Ask the primary caregiver if the patient could not describe, validate through home visitation, coordinate with
Barangay officials)
1. Home Evaluation:
a. Residence description (types of home, number of floors, steps, rooms)
b. Outside entrance (number of entrances, locations, stairs, rails, ramps)
c. Kitchen (doorways, light switches, electrical switches (grounded?), cords, counter heights, location of furniture, appliances)
d. Inside stairs (usage by patient, number of stairs, lighting, locations, railing)
e. Bedroom (accessibility, width of door, adequate size, lighting, switches, outlets, cords, phone, height of bed, night lights,
furniture, etc)
f. Bathrooms (number of bathrooms, locations, width of doors, adequate room, location of sink, height of sink/toilet, tub with
shower – height of tub, shower only,
TP holder, rugs, non-slip mats, bench/chair, grab bars)
g. Laundry (location, style of W/D)
h. Living room (accessibility to client, floor surfaces, rugs, lighting, switches/outlets, electric cords, TV/radio, phone, furniture,
where does client sit most often)
i. Other rooms
j. Barriers
k. Is there room for live-in assistance?
2. Is patient able to call for emergency help? What is the number?
3. Is the patient able to safely navigate their home? i.e. stairs
F. Hobbies/Interests
1. What activities do they enjoy doing?
2. Are they still able to participate in their hobbies/interests?
3. What physical limitations do they have?
4. If they do have physical limitations what are some ways they can still engage in the activity in some way?

G. Nutrition Screen
a. Have you made any changes in the way you eat because of illness or medical condition?
b. Do you eat fewer than two meals a day?
c. What do you normally eat?
d. Do you have teeth or mouth problems which make it difficult for you to eat?
e. Do you have three or more alcoholic drinks per day?
f. Do you eat alone most of the time?
g. Do you have enough money for food?
h. Do medications affect your appetite?
i. Have you lost or gained more than 10 lbs. in the last month?
j. Are you usually able to shop, cook, and feed yourself?
k. Do you have difficulty with:
 Swallowing  Indigestion  Heartburn  Diarrhea  Vomiting  Constipation
l. Do you take a laxative regularly?
m. Do you take a diuretic regularly?
n. Do you follow a special diet? If so, what type?
o. Are you able to prepare cereal, sandwiches or reheat meals?
p. What did you eat for breakfast/lunch/dinner today?

H. Spiritual/Religious Preferences
a. Does the patient identify with a specific religion?
•What role does that religion play in their life?
•Is their religious community a support to them?
•What role does their religion play in their view on aging and end of life?
b. Is the patient spiritual?
•How do you perceived is the reason why you are going through this present experience/situation
c. How are their religious and spiritual needs met?
I. Work History
a. What is their work history?
b. Did they enjoy their work?
c. When did they retire?
•Have they enjoyed retirement?
•Have physical limitations put restraints on what they wanted to do in retirement?
•Are they bored not working/what do they do with their time now?
J. Insurance/Financial
What is their financial situation?
• Retirement
• Pension
•Do they have Life Insurance?
•Do you have a Social Pension from DSWD?
K. Advance Directives (Only for patients with terminal illness)
a. Does the patient have an Advance Directive/Medical Power of Attorney/Living Will/Portable Medical Orders (POST) or Personal
Health Record and is it up to date?
•Who will make treatment decision for you when you will not be able to do it anymore?
•Did you sign a do not resuscitate/ do not intubate (DNR/DNI) form?
b. If they do not have one, are they comfortable with their Next of Kin making decisions for them if they’re unable to?
c. If they do not have one, have they at least had the conversation and communicated with their wishes are to their loved ones?
L. Independence Level
a. What ADL’s are they able to do themselves?
b. Who helps them with their ADL’s if they need help?
c. What are their worries about not being independent or staying independent if they still are?
d. Are they still able to enjoy the activities they used to?
e. What ADL’s are they able to participate in?
 Eating/Meal  Bathing  Dressing  Grooming   Continence
Preparation Transferring/Mobility
 Money Management  Telephoning   Transportation  Medication
Laundry/Housework Management
f. Do they have any of these services already in place?
 Physical Therapy  Occupational Therapy  Respiratory  Home Delivered Meals
Therapy
 Chore Services  Transportation  Private Pay  Hospice  Other
Assistance
M. Mental Health
a. Do you have any mental health history?
• What kind?
•What treatment have you had?
• Is it well controlled?
•What impact does it have on your daily life?
b. Have you had any current/past suicidal ideations?
c. Have you noticed a change in your mood since retirement/loss of independence/other life event?
N. Elder Abuse: Check presence of symptoms
1. Abuse
 Unexplained bruises or welts  Multiple bruises in various stages of  Unexplained fractures, abrasions and
healing lacerations
 Multiple injuries  Low self-esteem or loss of self-  Withdrawn, passive,  Reports or suspicious of sexual abuse
determination fearful
2. Neglect
 Dehydration  Malnourishment  Over or under medicated  Deserted or abandoned
 Inappropriate or soiled clothes  Lack of glasses, dentures or other aides if usually  Unattended
worn
3. Self- Neglect
 Malnourishment or Dehydration  Lack of glasses, dentures or hearing aids, if  Failure to keep medical appointments
needed
 Over or under medicated  Social isolation  Unkempt appearance
4. Exploitation
 Disappearance of possessions  Overcharged for home  Inadequate living  No money for food or
repairs environment clothes
 Unable to afford social activities  Forced to sell house or change one’s  Forced to sign over control of finances
will
O. Assess for Dementia Indicators
 Tendency to  Inability to be  Repetitive  Rummaging  Hoarding  Sun downing
wander alone actions
 Hiding/losing items  Suspiciousness  Incontinence   Sleep disturbances
Agitation/Restlessness
 Inappropriate sexual  Does the patient drive?  Are there safety issues?  Family Concerns?
behaviour
P. Assessment Statement:

Conforme:
Prepared by:

Patient/Guardian Signature/Thumb Mark Medical Social Worker

Licensed No.:________________