From Fulmer and Cahill (1984).

Elder Assessment Tool
  1. Date________________

  2. Person completing form____________________________

  3. Patient age___________

  4. Patient sex Male____ Female____

  5. PAYMENT STATUS __Medicare __Private Pay __Other

  6. RESIDENCE __Home __Nursing Home __Other

  7. ACCOMPANIED BY __Family __Friend __Alone

  8. MENTAL STATUS __Alert __Confused __Unresponsive

  9. REASON FOR VISIT __Orthopedic __Changed Mental Status __Other

GENERAL ASSESSMENT

  1. Hygiene ____yes ____no

  2. Nutrition ____good ____fair ____poor

  3. Clothing ____good ____fair ____poor

USUAL LIFESTYLE

  1. Maintenance of hygiene ____self ____assist

  2. Continent of bowel/bladder ____self ____assist

  3. Feedings ____self ____assist

  4. Ambulatory ____self ____assist

  5. ____Housebound ____Outings

  6. ____Sedentary ____Active

  7. Personal contact with ____family ____friends ____nursing home personnel

  8. Happy with living situation ____yes ____no

  9. Who manages finances ____self ____family ____other?

  10. Does financial arrangement work well ____yes ____no?

  11. If care provider is present, is the observed relationship ____good ____poor ____indifferent ____doesn’t apply

  12. History of recent life crisis ____yes ____no ____unsure

  13. PHYSICAL ASSESSMENT (evidence of)

    ___bruising ___lacerations ___abrasions

    ___diarrhea ___urine burns ___decubiti

    ___dehydration ___malnutrition ___alcohol abuse



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