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3. How can you learn best? ___Studying by yourself ___Through listening to others ___Through reading

4. How are you doing in school or at work? ___________none_______________________________ _____________________________________________

4. Emotional Pattern1. What type of mood are you usually in?

___Calm ___Depressed ___Pleasant ___Happy ___Excited ___AgitatedOthers:

________________________________________________ ________________________________________________

2. How do you express yourself during mood changes? ___Verbally ___Non-Verbally

3. Do your relations with others changes with your moods? ___Yes ___NoHow?

________________________________________________ _______________________________________________

5. Self-concept1. What was your highest weight? ___120 lbs__

2. How do you feel about your weight and appearance? ___Satisfied ___Non-satisfied

3. Have you had any physical alteration to your body? ___Yes ___No

4. How do you see yourself in relation to others? ___Equal ___Better than ___Less than

5. What are your goals for the next 5 years? ___mamasyal kasama buong family ko ________________________________________________

6. What are your good and bad qualities? _Mabait sa mga bata at naninigaw ako paggalit_____________________________________________

6. Sexuality 1. How do you express yourself as a woman/man?

___Nagdadamit ako ngpambabae____________________________________

2. Has your health concern changed the way you expressyourself as a woman/man?

__oo kasi tingin ko hindi akonormal_______________________________________

3. What do you enjoy/ not enjoy about being awoman/man?

_>magtatrabaho at nakakatulong ________>makikipag barkada____________________

4. Do you have any problems regarding what others wantyou to do as a woman/man and what you want othersto show affection toward you?

___Yes ___NoWhy?

_____________________________________________ ____________________________________________

5. How do you show affection toward others? How doyou want others to show affection toward you?

_>nakikipag usap at nakikipag tawanan pag hug at pag kiss ________________________

7. Family Copping Patterns1. How does your family handle stress? Be specific foreach member of the family?> pinag uusapan naming lahat

______________________________________________

2. How does your family make decisions? Who has the lastword?>nag uusap at nagbibigay ng opinion.Ako____________________________________________

3. If someone in the family gets sick, who is the caretaker?Anak kong babae________________________________

_____________________________________________

4. What is your role or place in the family? _tagapayo_______________________________________ _____________________________________________

B. Socio-cultural Health1. Cultural Pattern

2. Significant Relationships

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3. Recreational Activities

4. Environment

1. What type of indwelling do you live in? ___Multiple dwelling ___Single dwelling

2. Are you comfortable where you live? ___Yes ___NoWhy?

_________________________________________ ________________________________________

3. Do you feel you have enough space to yourself? ___Yes ___NoWhy?

_________________________________________ ________________________________________

4. Is your place easy to move in? ___Yes ___No

5. Are the sounds, noises or odors in theenvironments that are concern to you?

___Yes ___NoWhat?

_________________________________________

________________________________________

C. Spiritual Health1. Religious beliefs and practicesusog, patawas, bawal magwalis pag gabi, bawal maligo pagmay dalaw kasi nakakabaliw at bawal matulog ng basa angbuhok kasi nakakabaliw

2. Values and valuingmagdasal bago kumaen

III. Activities of Daily Living1. Nutrition

a. How many times do you eat in a day? ___3________

b. Do you have any difficulty in eating? ___Yes ___No

c. Do you avoid certain foods? ___Yes ___No

d. How many glasses of fluid do you take in a day? ________12_______________What kind of fluid do you usually drink?

___Coffee ___Soft drinksOthers:

_______________________________________ _______________________________________

2. Hygienea. How many times do you take a bath in a day?

___1_____________________

b. How many times do you brush your teeth? __2______________________

c. How many times do you trim your nails in aweek?

__2______________________

d. Dou you use cologne or perfume? ___Yes ___No

e. Are you able to attend to your personal self-careneeds?

___Yes ___NoWhy?

_______________________________________ _______________________________________

3. Rest and sleep a. How many hours do you sleep in a day?

________6__________________

b. Do you take naps? ___Yes ___NoWhy?__kasi nakakahigh blood______________ _______________________________________

How many hours? _________________________

c. Do you have any difficulty in getting sleep? ___Yes ___NoWhy?

______________________________________ _______________________________________

d. What do you do with these difficulties? _______________________________________ ______________________________________

4. Exercise a. Do you exercise regularly?

___Yes ___No

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Why? _______________________________________ _______________________________________

b. How many times do you exercise in a week? ________evryday________________________

c. What form of exercise? _______walking and sweeping______________

5. Eliminationa. How many times do you urinate/void in a day?

___________8_________________

b. Do you have difficulty in void? ___Yes ___NoWhat?

_______________________________________ ______________________________________

c. How many times do you defecate in a day? ______________________________________

d. Do you have difficulty in defecating? ___Yes ___NoWhy?

______matagal matunawan________________ _____________________________________

6. Sexual Activitya. Do you still engage in sexual activities?

___Yes ___No

Why? _______________________________________ _______________________________________

b. Do you have difficulties in engaging in sexualactivities?

___Yes ___NoWhat?

_______________________________________ ______________________________________

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Far Eastern UniversityInstitute of Nursing

Assess Tool for Elderly

INTEGUMENTARY CHANGES ___Dry skin

___Itchiness of skin ___Decrease sensation ___ Lentigo senilus (Brown age spots) ___Pale skin ___Hollow or gaunt hand ___Baldness and hair loss ___Loss of hair and color (gray/white hair? ___Thickened and brittle fingernails ang toenails ___Double chin ___Sagging eyelids and earlobe ___Wrinkles ___(In women) breast are smaller amd may sag ___Decrease tolerance to cold

BODY TEMPERATURE ___Decreased body temperature

NEUROMUSCULOSKELETAL CHANGES ___Slowed voluntary or automatic reflexes ___Decreased ability to respond to multiple stimuli ___Easy tiring ___Kyphosis (humpback to upper spine) ___Stiffness of joint

___Visible bony prominences ___Limited range of motion

CARDIOPULMONARY CHANGES ___Short breaths taken ___Dyspnea ___High blood pressure

SENSORY PERCEPTUAL CHANGES

Visual: ___Shrunken eyes ___Slowed blink reflexes ___Blurry vision ___Decreased color perception ___Decreased night vision ___Decreased tear production ___Increased sensitivity to glare

Hearing: ___Decreased ability to distinguish high frequency sounds ___Decreased ability to hear

Taste and Smell ___Less stimulated by food

Pain and Touch ___Increased threshold for sensations

GASTROINTESTINAL SYSTEM

___Impaired mastication ___Decreased gag reflex ___Decreased salivary production ___Increased incidence of haiatus hernia ___Constipation

URINARY CHANGES ___Urinary urgency ___Urinary frequency ___Nocturnal frequency ___Increased concentration of urine

MOOD ___Nervous with strangers ___Difficulty in making decisions ___Lack of concentration of memory ___Lonely or depressed ___Cries often ___Hopeless outlook ___Difficulty relaxing ___Worries a lot ___Frightening dreams or thoughts ___Shy or sensitive

___Dislikes criticism ___Losses temper ___Annoyed by little things