Elderly Sheet at out patient clinic
I- Socio-demographic data:
- Name of the elderly:
- Age: sex:
- Social status: Single ( ) Married ( )
Divorced ( ) Widow ( )
- Level of education ………………………………
-Occupation before retirement: - …………………..
- Number of family members:
- Person sponsoring him / her ……………………..
II- Health history:
- Medical diagnosis:———————————————-
-Family history of chronic disease :——————————-
-Present complains (S&S):----------------------------------------------
- Increase of symptoms with :——————————————-
-Duration ——————————————————————
-Measures taken by the client ————————————————
-Discovery of disease and onset of symptoms :
---------------------------------------------------
—————————————————————————-
-Start of treatment: ----------------------------------------------------—
III- Physical assessment:-
Nutritional habits and problem:
- Special diet ( ) - Ordinary diet ( )
- Frequency of meals/day: ---------------------
- Amount of fluid intake/day: ------------------
- Smoking habits: Yes ( ) No ( )
- Tea ( ) Coffee ( ) Others ( )
- Other specify: -------------------------------------------------------
Skin Condition:
- Redness ( ) -Itching ( ) - Bed sores ( ) -Cold ( )
- Hematoma ( ) Pale ( other )
Eye condition:
- Inflammation'' conjunctives '' ( ) - Glaucoma ( )
- Cataract ( ) Other specifies: ------------------------
Ears condition:
-Inflammation ( ) -Discharge ( )
- Hearing condition: -Normal ( ) - Impaired ( )
Nose condition:
- Discharge ( ) -Epistaxsis ( )
- Other specify --------------------------
Oral condition:
- Bleeding from gum ( ) - Loss of teeth ( )
- Other specify ----------
Respiratory system:
Cough: -Dry ( ) -Productive ( )
- Dyspnea ( ) - Orthopnea ( )
- Other specify -------------------
Gastrointestinal Tract System G.I.T.
- Heart burn ( ) Indigestion ( )- Abdominal distention ( )
- Constipation ( ) Diarrhea ( ) Heamorids ( )
- Other specify --------------------------------------------------
Circulatory system:
- Hypertension ( ) -Chest pain ( ) - Atherosclerosis ( )
-Heart failure ( ) - Myocardial infarction ( )
-Varicose vein ( )
- Other specify: ………….
Musculoskeletal system:
-Arthritis ( ) Back pain ( )
- Joint pain ( ) joint swelling ( )
- Osteoporosis ( ) Other specifies: ----------------
Genito- urinary System:
Polyuria ( ) Dysuria ( ) incontinence ( ) Hematuria ( )
Urgency ( )Stress incontinence ( ) Enlarged prostate ( )
Vaginal bleeding ( ) Excessive vaginal discharge ( )
Dyspareunia ( ) Infection ( ) other specify ( )
Neurological problems:
- Numbness ( ) -Parathesia ( )
- Neuropathy ( ) -Other specify ……………..
Laboratory data:
- Fasting blood sugar: -----------------------------------------------------
- Urine: ----------------------------------------------------------------------
- Others: ---------------------------------------------------------------------
- Patient self-testing for glycosuria (report in terms of, frequency)
IV- Psychological assessment: -
- Not able to adjust to life: ( )
- Always live in the past: ( )
- Feels lonely: ( )
- Depression: ( )
- Other specify: ( )
V- Social assessment
-Ability to discuss present current events
-Able ( ) Confused ( ) Low power of concentration ( )
- Specific hobbies or interests:
Walking ( ) Reading ( )
- Watching television ( ) - Listening to radio ( )
- Other specify
-The elderly Visits the family members and friends: Yes ( ) No ( )
-The elderly family and friends Visits the elderly: Yes ( ) No
( )
-The elderly can participate in social activities such as wedding:
Yes ( ) No ( )
*Medication:
Dose/ Frequency Route Name
Health Education
Health Education Need or Problem
Dat
e
