. "10. Elder Mistreatment: Epidemiological Assessment Methodology." Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, DC: The National Academies Press, 2003.
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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America
From Fulmer and Cahill (1984).
Elder Assessment Tool
Date________________
Person completing form____________________________
Patient age___________
Patient sex Male____ Female____
PAYMENT STATUS __Medicare __Private Pay __Other
RESIDENCE __Home __Nursing Home __Other
ACCOMPANIED BY __Family __Friend __Alone
MENTAL STATUS __Alert __Confused __Unresponsive
REASON FOR VISIT __Orthopedic __Changed Mental Status __Other
GENERAL ASSESSMENT
Hygiene ____yes ____no
Nutrition ____good ____fair ____poor
Clothing ____good ____fair ____poor
USUAL LIFESTYLE
Maintenance of hygiene ____self ____assist
Continent of bowel/bladder ____self ____assist
Feedings ____self ____assist
Ambulatory ____self ____assist
____Housebound ____Outings
____Sedentary ____Active
Personal contact with ____family ____friends ____nursing home personnel
Happy with living situation ____yes ____no
Who manages finances ____self ____family ____other?
Does financial arrangement work well ____yes ____no?
If care provider is present, is the observed relationship ____good ____poor ____indifferent ____doesn’t apply
History of recent life crisis ____yes ____no ____unsure
