GERIATRIC CASE
Section I: Identification Details
Name:
Age:
Sex:
Marital Status : Married/ Widow /Widower/ Separated/ Single
Monthly Income (if any):
Write the details of any pension
being received from government
social security scheme
For females only
Menopause
Age of menopause
Type of menopause:
Natural/ Surgical
Section II: History of Present Illness
Chief Complaints (Chronological order)
Details of Chief Complaints
Past History
Family History
Treatment History
(Medication/Dose, Schedule, who
prescribed the medicine, Reason for
prescribing medicine)
Hospitalization history
Personal history
(H/O Substance abuse, Type of diet etc)
Any Allergies:
Social History
(No. of children, relationship with family,
relatives and neighbours)
Immunization History
Sleep History
Section III: Activities of Daily Living (using Katz index in ADL)
Katz Index of Independence in Activities of Daily Living
Activities Independence Dependence
Points (1 (1 Point) (0 Points)
or 0)
NO supervision, direction or personal WITH supervision, direction,
assistance. personal assistance or total care.
BATHING (1 POINT) Bathes self completely or (0 POINTS) Need help with
needs help in bathing only a single part of bathing more than one part of the
Points: __________ the body such as the back, genital area or body, getting in or out of the tub
disabled extremity. or shower. Requires total bathing
DRESSING (1 POINT) Get clothes from closets and (0 POINTS) Needs help with
drawers and puts on clothes and outer dressing self or needs to be
Points: __________ garments complete with fasteners. completely dressed.
May have help tying shoes.
TOILETING (1 POINT) Goes to toilet, gets on and off, (0 POINTS) Needs help
arranges clothes, cleans genital area transferring to the toilet, cleaning
Points: __________ without help. self or uses bedpan or commode.
TRANSFERRING (1 POINT) Moves in and out of bed or (0 POINTS) Needs help in
chair unassisted. Mechanical transfer aids moving from bed to chair or
Points: __________ are acceptable requires a complete transfer.
CONTINENCE (1 POINT) Exercises complete self-control (0 POINTS) Is partially or
over urination and defecation. totally incontinent of bowel or
Points: __________ bladder
FEEDING (1 POINT) Gets food from plate into (0 POINTS) Needs partial or
mouth without help. Preparation of food total help with feeding or
Points: __________ may be done by another person. requires parenteral feeding.
TOTAL POINTS: ________
SCORING: 6 = Full function
4= Moderate Impairment
2or less = Severe functional impairment
Adherence to treatment in case of any chronic illness
Using MARS-5 scale
Item Always Often Sometimes Rarely Never
1. I forget to take
them
2. I alter the dose
3. I stop taking
them for a
while
4. I decide to miss
out a dose
5. I take less than
instructed
The higher the score, the better is the adherence to treatment in case of chronic illness.
Section IV: Dietary History
Meal Day 1 Day 2 Day 3 Total Average
Consumption intake
Food Quantity Food Quantity Food Quantity
item item item
Morning
Tea
Breakfast
Midmorning
snack
Lunch
Evening tea/
snack
Dinner
Post dinner
Food item Quantity (average Calories Proteins
consumption/ day)
Total Consumption
Recommended
Excess (+)/ Deficit (-)
Section V: General Physical Examination
Pulse Rate:
Blood Pressure:
Respiratory Rate:
Temperature:
Oedema
Lymphadenopathy
Pallor
Cyanosis
Clubbing
Built
Orientation
Section VI: Systemic Examination
Skin: Normal/Dry/ Rash/ Itchy/ Ulcers/ Lustre less
Eyes: Arcus Senilis/Cataract/ Refractive error/Ptyregium/ any other
Oral cavity: Oral hygiene: Good/ Average/ Poor
Halitosis: Yes/ NO
Gums: Normal/Hypertrophied/ Bleeding/ Periodontitis
Dentition:
No. of Teeth: / Edentulous
DMF index:
Wears any: Removable Partial denture / Full Denture
Tongue: Normal/ Coated/ Atrophic Glossitis
Ears/ Hearing: Normal/ Presbycusis
Type of loss: Sensory / Conductive
Give the details of
Rinne’s Test
Weber’s Test
Abdomen/ Gastrointestinal system
Inspection Palpation Auscultation Percussion
Abdomen
Chest/ Respiratory system
Inspection Palpation Auscultation Percussion
Chest
Cardiovascular system
Inspection Palpation Auscultation Percussion
Chest
Central nervous system
Cranial nerves
Motor Examination
Strength
Posture
Gait
Cerebellar function
Sensory Examination
Reflexes
Superficial
Deep
Elderly Cognitive Assessment Questionnaire ECAQ Memory
1) I want you to remember this number can you repeat after me 4517?
2) How old are you?
3) When is your birthday? Or where were you born? Orientation information
4) What day of the week is this? What is the date today?
5) Day? 6) Month? 7) Year?
8) What is this place called (eg: clinic, hospital) No necessity to give name of place
9) What is his / her job (eg: nurse, doctor) Memory recall
10) Can you recall the number again?
Results Each right answer will be given 1 point.
5 points and below - high risk of cognitive impairment.
Musculoskeletal system
Inspection Palpation Movement of Joints
Chest
Lab Investiagtions:
Hb:
RBS/FBS:
BP:
Any other (write details):
MARS-5 score:
Remarks:
Note: If the case is suffering any chronic illness, check related hospital records and investigations.
Section VII: Treatment Seeking Behaviour
1. From where do you seek treatment for minor ailments?
2. Are your family members willing to take you for treatment every time? Yes/ No
No. of government schemes available for geriatric Availed or not availed
Clinico-social Diagnosis:
Recommendations (if any)
At individual level
At family level
At community level
PROGRESS REPORT
DATE OF Hb RBS/FBS BP HEIGHT WEIGHT BMI ANY H/O PRESENT ILLNESS MARS-5 SCORE
VISIT
