Age-friendly Primary Health Care Centres Toolkit - World Health ...

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AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKITII.4.1 Overall examinationOverall exam sheetNote: If there are national forms, please use.PART 1 – CAN BE DONE BY NURSE OR TRAINED HEALTH CARE WORKERDate:___________ Name:__________ <strong>Age</strong>:____________Sex: Male FemaleVital Sign:BP:_______ Pulse:______ Temperature:________ Weight:_____ Height:_______Social History:Martial Status:_________Native language:___________Who are you living with ? __________Do you have any children ? Y / N How often do you see them ?___________Who assists you ? ______________ Is it sufficient ? Y / NIn which type of housing do you live ?_____________Are there stairs ? Y / NFamily HistoryHypertension Diabetes DementiaHeart disease Others________Past Medical History (check positives)hypertension cardiovascular disease thyroidcholesterol stroke neuropathy peripheral vasculardiabetes hepatitis head injury Parkinson’salcohol depression seizures cancerhear, visionROS (do appropriate to complaint include psychiatric history)Level of Function (ADL-Tool 7):Independent Need assistance DependentPART 2 – TO BE DONE BY DOCTOR (do sections appropriate to exam)Eyes normal conjunctiva & lidsPupils pupils symmetrical, reactiveENT-External no scars, lesions, massesOtoscopic normal canals & timpanic membranes38
AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKITAnt. OralOropharynxNeck palp.Thyroid normal lips, teeth, gums normal tongue, palate symmetrical without massesno enlargement or tendernessResp.Respiratory rate :_____per minChest percuss. no dullness or hyper resonanceAuscultation normal bilateral breath sounds without ralesHeart palp.Cardiac ausc.CarotidsPedal pulsesBreastsAbdomenL/SHernia normal location, sizeno murmur normal intensity without bruit normal posterior tibial & dorsalis pedisnormal l inspection & palpationno masses or tendernessno liver/spleenno hernia identifiedGenitourinary male external genitalia normal without lesionsProstate normal size without nodularityGenitourinary femaleInt. inspection normal bladder, urethra, & vaginaCervix normal appearance without dischargeUterus normal size, position, without tendernessAdnexano masses or tendernessAdditional description of positive findings (including behavioural changes):Preliminary diagnostic assessment (impairment level, co morbid health conditions,potential treatable elements):39
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Ageing and Life Course (ALC)Family
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