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) Sept 20,202

2.) File No.: ___
3.) lInterviewer (Tagapanayam):
Medenilla,Gemalyn B.
DEMOGRAPHICS (DEMOGRAPIYA)

4.) Name (Pangalan):____Orlando C.

Bautista
Nickname (Palayaw): ___Orlan_
5.) Age in years (Edad): __64

6.) Sex (Kasarian): ✓ Male (Lalaki)  Female (Babae)

7.) Address (Tirahan): _Brgy Diket Umingan Pangasinan_________________________

8.) Place of birth (Lugar ng Kapanganakan): ___Brgy. Diket Umingan
Pangasinan__________________
9.) Telephone no. (Numero ng telepono): ________ Mobile no. (selfon) :
_09956723841_______
10.) Civil Status (Katayuang Sibyl)

 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?)
__________________________________________________________________
_______________

B. If 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)?

__Farmer/Tricycle driver

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-alagaang✓ Yes
(Oo) No (Hindi) If Yes, who is your primary caregiver (Kung meron, sino po ang inyong
pangunahing tagapag-alaga)?

_____________Asawa__________________

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)?______Padre de Palmilya________________

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)? ____Since 20 Years old____________

How many sticks per day (Ilang istik/piraso sa isang araw)? _5 Sticks_____

B. Have 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?)___________________
 C. Have 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?)___________________

E. Do 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 2 times a week 30mins.
 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) watching tv_____

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)? _Dr.
Trinidad_____________________________________

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 Illness Date Date Course of Action (Mga

(Sakit) Started Resolved ginawang aksyon)
(Petsa ng (Petsa ng
Pagsisimula Pagresolba)
) Year Year (Taon)
(Taon)
_____________Hypertension__________ __august 10 Aug. 13 202___ ___Maintenance/Medication___
_______ _____ ______
__________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____
 __________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____
__________________________________ _____________ _____________ _____________________
____ ____

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

Motoprolol 500mg OD

Losartan 500mg OD

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 
(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
Using the telephone (Paggamit ng ✓
Bathing (Pagligo) ✓
telepono)
Dressing (Pagbihis) ✓ Shopping (Pamimili)
Food preparation (Paghanda ng pagkain) ✓
Toileting (Pagbanyo) ✓
Housekeeping (Pag-ayos o paglinis sa
Transfers (Pagbangon) ✓ bahay)
Laundry (Paglalaba)
Continence (Pagpigil sa Transportation (Pagsakay) ✓
ihi o dumi)
Taking medicine (Pag-inom ng gamot) ✓
Feeding (Pagkain) ✓
Managing money (Pangangalaga ng pera) ✓
ADL Score 5 IADL Score 5

Physical Examination

BP (mmHg): Standing: _150/110___ Sitting: __130/100____ HR (bpm): __75___ RR: __19___

Height (cm): __165cm__ Weight (kg): _75Kg___ BMI (kg/m2): 24.5__ *Proceed to MNA-SF if BMI is
<18.5 or >23
Hip circumference (cm): _____________ Waist circumference (cm): _95cm_______ WH
Ratio: 0.90__ Demi span (cm): R ___73 cm______ L ____73cm______ General:

Pain  Yes (Oo) ✓ No (Hindi)

Location

VISUAL ANALOG SCALE (VAS)

 0 10

NO PAIN SEVERE PAIN HEENT:

Vision Hearing

Visual acuity: ______________________ Rinne’s test: __________________________

Gross examination: _________________ Weber’s test: _________________________

Otoscopic exam: _______________________

Chest/Lungs:

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?

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:
_____________________________________________________________________

B. Cranial Nerves
Normal (-) Abnormal (+)

II. Fundus

Visual Fields

Visual Acuity

III, IV, VI

VII

VIII

IX, X

XII

C. Manual muscle testing D. Motor Exam

 Grading (0-5) Muscle strength:
_____________4______________
Muscle group R L
Extrapyramidal: ____________________________
neck flexors 4 4
Muscle atrophy/hypertrophy:
shoulder abductors 3 3 _________________

shoulder adductors 3 3 Muscle tone:  Spastic ✓ Rigid 

Flaccid
elbow flexors 4 4

elbow extensors 4 4

wrist flexors 3 3

wrist extensors 4 4

grip 3 3

hip flexors 4 4

hip extensors 4 4

knee flexors 4 4

knee extensors 4 4

foot dorsiflexors 4 4

foot plantarflexors 4 4

 Passive movement of the joint

 Slowness and reduce spontaneity
Endurance: ____________________ 

Fatigability
Presence of spontaneous movements:

 Fasciculation  Tremors

E. Reflexes
 Remarks:

_______________________________________________

_______________________________________________

_______________________________________________

F. Sens
Normal Abnormal Findings a
Findings t
Normal Abnormal
Light touch ✓ i
Posture ✓o
Pain/temperature ✓ n
G. Functional reach ✓
Joint ✓
position/vibratory Time up and go test ✓

Coordination and Gait Cerebellar signs ✓

Summary of Findings

The Patient is a tricycle driver, he is 64 years old. and he has Hypertension. maybe because he
was on the road every day and exposed to the heat. and also inevitable due to aging. As we grow
older our vascular system changes. As a result, Our blood pressure increases. the reasons why He
became tricycle driver until now, is that they are poor and this is the available job for him
because He only reach 2nd year High school.

He is now with his wife and they have three Children but only his wife takes care of him because their
children have their own families as well.
________________________________

Signature over Printed Name

_____________________________
MD Signature over Printed Name