STATUS PASIEN HOME VISIT PUSKESMAS KEJAKSAN STATUS PASIEN I.

IDENTITAS PASIEN
Nama Umur Jenis Kelamin Pekerjaan Alamat Status Perkawinan Tanggal kunjungan II. ANAMESIS a. Keluhan Utama b. Keluhan Tambahan : Sering Kencing pada malam hari : : Hj Usniyah :70 tahun :Perempuan : IRT :Kesenden Rt /Rw 03 /02 : Menikah :

c. Riwayat Penyakit Sekarang Pasien mengeluhkan bahwa akhir-akhir ini sering buang air kecil saat malam hari (kurang lebih sekitar empat kali) dan pasien pun sering merasa kawatir karena cucunya sering pulang larut malam rasa kawatir tersebut yang paling sering menyebabkan pasein sering baung air kecil. Rasa haus saat malam hari di sangkal pasien.Untuk makanan dan minuman pasien dapat menjaga dan menghindari seperti makanan dan minuman yang manis,kacang-kacangan,singkong,kangkung dan bayam. pada bulan November tahun 2012 yang lalu pasien memiliki riwayat asam urat tinggi (9) dampak dari asam urat itu kedua kaki pasien mengalami bengkak dan susah untuk berdiri dua hari sebelumnya pasien mengkonsumsi kacang tanah dan singkong goreng. Untuk aktivitas sehari-hari pasien tidak memiliki masalah namun untuk jalan jarak jauh pasien tidak mampu d. Riwayat Penyakit Dahulu Diabetes Mellitus Hipertensi

 Gangguan pada jantung e. Riwayat Penykit Keluarga: Bapak kandungnya memiliki riwayat ` Hipertensi

f. Riwayat Kebiasaan Sosial Sering menkosumsi makanan dan minuman manis makanan yang di goreng

III.

PEMERIKSAAN FISIK

a.Status Present Keadaan Umum Kesadaran Tekanan Darah Frekuensi Nadi Frekuensi Nafas Temperatur b.Status General Kulit Warna Turgor Ikterus Sianosis Kepala Bentuk Rambut Mata Telinga Hidung Mulut Bibir Gigi geligi Tenggorokan Faring Thorax Thoraks depan Inspeksi

: Baik :Compos Mentis : 170/80 mmHg : 72 x/menit : 18 x/menit : Afebris

: Sawo matang : Kembali cepat : (-) : (-) : Kesan Normocephali : Berwarna hitam dan putih, sukar dicabut : Cekung(-), refleks cahaya(+/+), ikterik (-/-) : Sekret (-/-), perdarahan (-/-) : Sekret (-/-), perdarahan (-/-) : Pucat (-), Sianosis (-) : Karies (-) : Tonsil dalam batas normal : Hiperemis (-)

Bentuk dan Gerak Tipe pernafasan Retraksi Palpasi Stem Fremitus

: Kesan simetris : Thorako-abdominal : (-) Paru kanan Paru kiri

Lap. Paru atas Lap. Paru tengah Lap.Paru bawah Perkusi Lap. Paru atas Lap. Paru tengah Lap.Paru bawah Auskultasi Suara pokok Lap. Paru atas Lap.Paru tengah Lap.Paru bawah

Normal Normal Normal Paru kanan Sonor Sonor Sonor Paru kanan Vesikuler Vesikuler Vesikuler

Normal Normal Normal Paru kiri Sonor Sonor Sonor Paru kiri Vesikuler Vesikuler Vesikuler

Suara tambahan Paru kanan Paru kiri Lap. Paru atas Rh(-) , Wh(-) Rh(-) , Wh(-) Lap. Paru tengah Rh(-) , Wh(-) Rh(-), Wh(-) Lap. Paru bawah Rh(-) , Wh(-) Rh(-), Wh(-) Jantung - Inspeksi : Ictus cordis tidak terlihat - Palpasi : Ictus cordis teraba ICS V linea axilaris anterior : ICS III sinistra - Perkusi : Batas atas Batas kanan : Linea parasternalis dextra Batas bawah : ICS V lines mid clavicula - Auskutasi : BJ I > BJ II, reguler, bising (-) Abdomen - Inspeksi : Kesan simetris, distensi (-) - Palpasi : Distensi abdomen (-), Nyeri tekan (-), H/L/G tidak teraba - Perkusi : Tympani usus (+), pekak hati (-), asites (-) - Auskultasi : Peristaltik usus (N) Ekstremitas Ekstremitas Sianotik Edema Ikterik Gerakan Tonus otot Sensibilitas Atrofi otot

Superior Kanan Kiri Aktif Aktif Normotonu Normotonu s S N N -

Inferior Kanan Kiri Aktif Aktif Normotonu Normotonus s N N -

Konseling Kasus Pasien diharapakan diharapakn untuk menjaga pola makan dan menghindari makanan dan minuman yang manis, kurang aktivitas berat dan selalu lakukan olahraga ringan seperti senan jantung dan cek gula drah dan asam urat setiap dua bula sekali.

HOME VISIT LANSIA

Tanggal : Nama : Hj Usniyah GERIATRIC ASSESSMENT CENTER ACTIVITIES OF DAILY LIVING PHYSICAL SELF-MAINTENANCE SCALE Instructions: Write in the appropriate value number on the score lines provided to the right of the responses. Add the value numbers to obtain total score. 1. TOILET 4 Cares for self at toilet completely, no incontinence 3Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents 2Soiling or wetting while asleep, more than once a week Soiling wetting while awake, more than once a week 0 No control of bowels or bladder 2. FEEDING 4 Eats without assistance 3 Eats with minor assistance at meal times, with help preparing food or with help in cleaning up after meals 2 Feeds self with moderate assistance and is untidy 1 Requires extensive assistance for all meals 0 Does not feed self at all and resists efforts of others to feed him 3. DRESSING 4 Dresses, undressed and selects clothes from own wardrobe 3 Dresses and undresses self, with minor assistance 2 Needs moderate assistance in dressing or selection of clothes 1 Needs major assistance in dressing but cooperated with efforts of other to help 0 Completely unable to dress self and resists efforts of others to help Value No 4 Value No 4 Value No 4

4. GROOMING 4 Always neatly dressed and well-groomed, without assistance 3 Grooms self adequately, with occasional minor assistance

Value No 4

2 Needs moderate and regular assistance or supervision in grooming

1Needs major assistance in dressing but cooperates with efforts of others to help 0 Actively negates all efforts to others to maintain grooming 5. PHYSICAL AMBULATION 4 Goes about grounds or city 3 Ambulates within residence or about one block distant 2 Ambulates with assistance of (check one): ____another person,___railing,____cane,_____ walker, or___wheelchair:____gets in and out without help___ needs help in getting in and out 1 Sits unsupported in chair or wheelchair, but cannot propel self without help 0 Bedridden more than half the time 6. BATHING 4 Bathes self (tub, shower, sponge bath) without help 3Bathes self, with help in getting in and out of tub 2Washes face and hands only, but cannot bathe rest of body 1 Does not wash self but is cooperative with those who bathe him 0 Does not travel at all 7. RESPONSIBILITY FOR OWN MEDICATION Value No 4 Value No 4 Value No 4

2 Is responsible for taking medication in correct dosages at correct time Takes responsibility if medication is prepared in advance in separate dosages 0 Does not try to wash self, and resists efforts to keep him clean TOTAL SCORE :

GERIATRIC ASSESSMENT CENTER SCALE FOR INSTRUMENTAL ACTIVITIES OF DAILY LIVING 1. ABILITY TO USE TELEPHONE 2 Dials a few well known numbers 1 Answers telephone but does not dial 0 Does not use telephone at all 2. SHOPPING 3 Takes care of all shopping needs independently 2 Shops independently for small purchases 1 Needs to be accompanied on any shopping trip 0 Needs to have meals prepared and served 3. FOOD PREPARATION 3 Plans, prepares and serves adequate meals independently 2 Prepares adequate meals if supplied with ingredients 1Heats and serves prepared meals, or prepares meals but does not maintain adequate diet 0 Needs to have meals prepared and served 4. HOUSE KEEPING 4Maintains house alone or with occasional assistance (e.g., heavy-work domestic help) 3 Performs light daily tasks such as dish-washing and bed-making 2Performs light daily tasks but cannot maintain acceptable level of cleanliness 1 Needs help with all home maintenance tasks 0 Does not participate in any housekeeping tasks Value No 3 Value No 3 Value No 3 Value No 3

3 Operates telephone on own initiative; looks up arid dials numbers, etc.

5. LAUNDRY 2Does personal laundry completely Launders small items; rinses socks, stockings, etc. 0 All laundry must be done by others

Value No 0

6. MODE OF TRANSPORTATION

Value No 1

4 Travels independently on public transportation or drives own car 3Arranges own travel via taxi, but does not otherwise use public transportation 2 Travels on public transportation when assisted or accompanied by another 1 Travel limited to taxi or automobile, with assistance of another 0 Does not travel at all 7. RESPONSIBILITY OF OWN MEDICATION Value No 2

2 Is responsible for taking medication in correct dosages at correct time 1 Takes responsibility if medication is prepared in advance in separate dosages 0 Is not capable of dispensing own medication 8. ABILITY TO HANDLE FINANCE goes toBank) collects and keeps track of income 1 Manages day-to-day purchases, but needs help with banking, major purchases, etc. 0 Incapable of handling money TOTAL SCORE : Value No 2

2 Manages financial matters independently (budgets, write checks, pays rent and bills,

I.
Nama Umur

IDENTITAS PASIEN
: Edi :61 tahun :Laki-laki :Wiraswasta :Kesenden Rw 05 : Menikah :

Jenis Kelamin Pekerjaan Alamat Status Perkawinan Tanggal kunjungan II. ANAMESIS a. Keluhan Utama b. Keluhan Tambahan

: Tidak ada keluhan, ingin cek TD :-

c. Riwayat Penyakit Sekarang pasien datang dengan tanpa keluhan hanya ingin cek tekanan darah,pasien memiliki penyakit Diabete Mellitus dan Hipertensi. walaupun pasien sering cek tekanan darah dan gula darah tapi pasien jarang minum obat, minum obat pun jika ada keluhan saja. Untuk masalah rokok pasien belum dapat bener-bener tidak mengkonsumsi rokok tetapi sekarang pasien dapat mengurangi rokok yang dulu sehari lebih dari satu bungkus dan sekarang satu bungkus sehari. d. Riwayat Penyakit Dahulu Diabetes Mellitus ( pada bulan oktober gula darah pasien sampe 600 dan pasien mengalami strok) Hipertensi

e. Riwayat Penykit Keluarga (-) f. Riwayat Kebiasaan Sosial Merokok

III.

PEMERIKSAAN FISIK

a.Status Present Keadaan Umum Kesadaran Tekanan Darah : Baik :Compos Mentis : 110/70 mmhg

Frekuensi Jantung : 72 x/menit Frekuensi Nafas Temperatur : 18 x/menit : Afebris

b.Status General Kulit Warna Turgor Ikterus Sianosis

: Sawo matang : Kembali cepat : (-) : (-)

Kepala Bentuk : Kesan Normocephali Rambut : Berwarna hitam dan putih, sukar dicabut Mata : Cekung(-), refleks cahaya(+/+), ikterik (-/-) Telinga : Sekret (-/-), perdarahan (-/-) Hidung : Sekret (-/-), perdarahan (-/-) Mulut Bibir : Pucat (-), Sianosis (-) Gigi geligi : Karies (-) Lidah : Beslag (-), Tremor (-) Mukosa : Basah (+) Tenggorokan : Tonsil dalam batas normal Faring : Hiperemis (-) Thorax Thoraks depan Inspeksi Bentuk dan Gerak : Kesan simetris Tipe pernafasan : Thorako-abdominal Retraksi : (-) Palpasi Stem Fremitus Paru kanan Paru kiri Perkusi Paru kanan Paru kiri Lap. Paru atas Sonor Sonor Lap. Paru tengah Sonor Sonor Lap.Paru bawah Sonor Sonor Auskultasi Suara pokok Paru kanan Paru kiri

Lap. Paru atas Lap.Paru tengah Lap.Paru bawah

Vesikuler Vesikuler Vesikuler

Vesikuler Vesikuler Vesikuler

Suara tambahan Paru kanan Paru kiri Lap. Paru atas Rh(-) , Wh(-) Rh(-) , Wh(-) Lap. Paru tengah Rh(-) , Wh(-) Rh(-), Wh(-) Lap. Paru bawah Rh(-) , Wh(-) Rh(-), Wh(-) Jantung - Inspeksi : Ictus cordis tidak terlihat - Palpasi : Ictus cordis teraba ICS V linea axilaris anterior

Perkusi

Auskutasi Abdomen - Inspeksi - Palpasi

-

: ICS III sinistra : Batas atas Batas kanan : Linea parasternalis dextra Batas bawah : ICS V lines mid clavicula : BJ I > BJ II, reguler, bising (-) : Kesan simetris, distensi (-) : Distensi abdomen (-), Nyeri tekan (-), H/L/G tidak teraba : Tympani usus (+), pekak hati (-), asites (-) : Peristaltik usus (N)

Perkusi - Auskultasi
-

Ekstremitas Ekstremitas Sianotik Edema Ikterik Gerakan Tonus otot Sensibilitas Atrofi otot

Superior Kanan Kiri Aktif Aktif Normotonu Normotonu s S N N -

Inferior Kanan Kiri Aktif Aktif Normotonu Normotonus S N N -

Konseling Kasus Pasien di harapkan untuk bener-bener berhenti dari rokok dan menghindari makanan yang berkolestrol dan makanan yang serba di goring, memasak dengan cara dikukus lebih baik.

HOME VISIT LANSIA

Tanggal : Nama : Edi GERIATRIC ASSESSMENT CENTER ACTIVITIES OF DAILY LIVING PHYSICAL SELF-MAINTENANCE SCALE Instructions: Write in the appropriate value number on the score lines provided to the right of the responses. Add the value numbers to obtain total score. 1. TOILET Value No : 4 4 Cares for self at toilet completely, no incontinence 3Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents 2Soiling or wetting while asleep, more than once a week Soiling wetting while awake, more than once a week 0 No control of bowels or bladder 2. FEEDING 4 Eats without assistance 3 Eats with minor assistance at meal times, with help preparing food or with help in cleaning up after meals 2 Feeds self with moderate assistance and is untidy 1 Requires extensive assistance for all meals 0 Does not feed self at all and resists efforts of others to feed him 3. DRESSING Value No : 4 Value No : 4

4 Dresses, undressed and selects clothes from own wardrobe 3 Dresses and undresses self, with minor assistance 2 Needs moderate assistance in dressing or selection of clothes 1 Needs major assistance in dressing but cooperated with efforts of other to help 0 Completely unable to dress self and resists efforts of others to help 4. GROOMING Value No : 4

4 Always neatly dressed and well-groomed, without assistance 3 Grooms self adequately, with occasional minor assistance 2 Needs moderate and regular assistance or supervision in grooming 1Needs major assistance in dressing but cooperates with efforts of others to help

0 Actively negates all efforts to others to maintain grooming 5. PHYSICAL AMBULATION 4 Goes about grounds or city 3 Ambulates within residence or about one block distant 2 Ambulates with assistance of (check one): ____another person,___railing,____cane,_____ walker, or___wheelchair:____gets in and out without help___ needs help in getting in and out 1 Sits unsupported in chair or wheelchair, but cannot propel self without help 0 Bedridden more than half the time 6. BATHING 3Bathes self, with help in getting in and out of tub 2Washes face and hands only, but cannot bathe rest of body 1 Does not wash self but is cooperative with those who bathe him 0 Does not travel at all 7. RESPONSIBILITY FOR OWN MEDICATION Value No : 1 Value No : 4 Value No : 4

4 Bathes self (tub, shower, sponge bath) without help

2 Is responsible for taking medication in correct dosages at correct time Takes responsibility if medication is prepared in advance in separate dosages 0 Does not try to wash self, and resists efforts to keep him clean TOTAL SCORE : 25

GERIATRIC ASSESSMENT CENTER SCALE FOR INSTRUMENTAL ACTIVITIES OF DAILY LIVING 1. ABILITY TO USE TELEPHONE 2 Dials a few well known numbers 1 Answers telephone but does not dial 0 Does not use telephone at all 2. SHOPPING 3 Takes care of all shopping needs independently 2 Shops independently for small purchases 1 Needs to be accompanied on any shopping trip 0 Needs to have meals prepared and served 3. FOOD PREPARATION 3 Plans, prepares and serves adequate meals independently 2 Prepares adequate meals if supplied with ingredients 1Heats and serves prepared meals, or prepares meals but does not maintain adequate diet 0 Needs to have meals prepared and served 4. HOUSE KEEPING 4Maintains house alone or with occasional assistance (e.g., heavy-work domestic help) 3 Performs light daily tasks such as dish-washing and bed-making 2Performs light daily tasks but cannot maintain acceptable level of cleanliness 1 Needs help with all home maintenance tasks 0 Does not participate in any housekeeping tasks Value No : 4 Value No : 3 Value No : 3 Value No : 3

3 Operates telephone on own initiative; looks up arid dials numbers, etc.

5. LAUNDRY

Value No : 2

2Does personal laundry completely Launders small items; rinses socks, stockings, etc. 0 All laundry must be done by others 6. MODE OF TRANSPORTATION Value No : 4

4 Travels independently on public transportation or drives own car 3Arranges own travel via taxi, but does not otherwise use public transportation 2 Travels on public transportation when assisted or accompanied by another 1 Travel limited to taxi or automobile, with assistance of another 0 Does not travel at all 7. RESPONSIBILITY OF OWN MEDICATION Value No : 2

2 Is responsible for taking medication in correct dosages at correct time 1 Takes responsibility if medication is prepared in advance in separate dosages 0 Is not capable of dispensing own medication 8. ABILITY TO HANDLE FINANCE goes toBank) collects and keeps track of income 1 Manages day-to-day purchases, but needs help with banking, major purchases, etc. 0 Incapable of handling money TOTAL SCORE : 23 Value No : 2

2 Manages financial matters independently (budgets, write checks, pays rent and bills,

STATUS PASIEN HOME VISIT PUSKESMAS KEJAKSAN STATUS PASIEN I. IDENTITAS PASIEN
Nama Umur Jenis Kelamin Pekerjaan Alamat Status Perkawinan Tanggal kunjungan II. ANAMESIS a. Keluhan Utama b. Keluhan Tambahan : Sering Diam : suka marah-marah dan tidak mau makan c. Riwayat Penyakit Sekarang : Istri pasien mengeluhkan bahwa sudah beberapa bulan ini pasien tidak dapat mengenali keluarganya termasuk pasien tidak tahu dirinya sendiri, cara bicara pasien sudah pelo dan tidak jelas dan sekarang juga pasien tidak bisa melakukan aktivitas sehari-hari secara mandiri semua kegiatan termasuk mandi,bak,bab,pakai/ganti baju memerlukan bantuan orang lain secara penuh. semua keperluan pasien istrinya yang menyediakan termasuk makan dan minum.Untuk sekarang istrinya memilih agar pasien selalu ada di rumah karena di kawatirkan akan pergi dari rumah. d. Riwayat Penyakit Dahulu : Suhandi :73 tahun :Laki-laki : Pensiunan : : Menikah :

 Jantung Koroner Pusing Kepala berat yang hilang timbul e. Riwayat Penykit Keluarga : f. Riwayat Kebiasaan Sosial : Merokok Apabila pusing kepala pasien sering mengkonsumsi paramex

III.

PEMERIKSAAN FISIK a.Status Present Keadaan Umum Kesadaran Tekanan Darah : Baik :Compos Mentis : 110/70 mmhg

Frekuensi Jantung : 72 x/menit Frekuensi Nafas Temperatur b.Status General Kulit Warna Turgor Ikterus Sianosis Kepala Bentuk Rambut Mata Telinga Hidung Mulut Bibir Gigi geligi Mukosa Tenggorokan : 18 x/menit : Afebris

: Sawo matang : Kembali cepat : (-) : (-) : Kesan Normocephali : Berwarna hitam dan putih, sukar dicabut : Cekung(-), refleks cahaya(+/+), ikterik (-/-) : Sekret (-/-), perdarahan (-/-) : Sekret (-/-), perdarahan (-/-) : Pucat (-), Sianosis (-) : Karies (-) : Basah (+) : Tonsil dalam batas normal

Faring : Hiperemis (-) Thorax Thoraks depan Inspeksi Bentuk dan Gerak : Kesan simetris Tipe pernafasan : Thorako-abdominal Retraksi : (-) Palpasi Stem Fremitus Paru kanan Paru kiri

Lap. Paru atas Lap. Paru tengah Lap.Paru bawah Perkusi Lap. Paru atas Lap. Paru tengah Lap.Paru bawah Auskultasi Suara pokok Lap. Paru atas Lap.Paru tengah Lap.Paru bawah

Normal Normal Normal Paru kanan Sonor Sonor Sonor Paru kanan Vesikuler Vesikuler Vesikuler

Normal Normal Normal Paru kiri Sonor Sonor Sonor Paru kiri Vesikuler Vesikuler Vesikuler

Suara tambahan Paru kanan Paru kiri Lap. Paru atas Rh(-) , Wh(-) Rh(-) , Wh(-) Lap. Paru tengah Rh(-) , Wh(-) Rh(-), Wh(-) Lap. Paru bawah Rh(-) , Wh(-) Rh(-), Wh(-) Jantung - Inspeksi : Ictus cordis tidak terlihat - Palpasi : Ictus cordis teraba ICS V linea axilaris anterior : ICS III sinistra - Perkusi : Batas atas Batas kanan : Linea parasternalis dextra Batas bawah : ICS V lines mid clavicula - Auskutasi : BJ I > BJ II, reguler, bising (-) Abdomen - Inspeksi : Kesan simetris, distensi (-) - Palpasi : Distensi abdomen (-), Nyeri tekan (-), H/L/G tidak teraba - Perkusi : Tympani usus (+), pekak hati (-), asites (-) - Auskultasi : Peristaltik usus (N) Ekstremitas Ekstremitas Sianotik Edema Ikterik Gerakan Tonus otot Sensibilitas Atrofi otot

Superior Kanan Kiri Aktif Aktif Normotonu Normotonu s S N N -

Inferior Kanan Kiri Aktif Aktif Normotonu Normotonus s N N -

Konseling Kasus : Kepada Istri pasien diharapakan untuk selalu membawa pasien ini control agar tahu perkembangannya seperti apa dan bagaimana keadaan pasien kedepannya karena pasien sangat perlu perawatan agar tidak fatal kedepannya.

HOME VISIT LANSIA Tanggal : Nama : Pak Suhandi GERIATRIC ASSESSMENT CENTER ACTIVITIES OF DAILY LIVING PHYSICAL SELF-MAINTENANCE SCALE Instructions: Write in the appropriate value number on the score lines provided to the right of the responses. Add the value numbers to obtain total score. 1. TOILET 4 Cares for self at toilet completely, no incontinence 3Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents Value No 0

2Soiling or wetting while asleep, more than once a week Soiling wetting while awake, more than once a week 0 No control of bowels or bladder 2. FEEDING 4 Eats without assistance 3 Eats with minor assistance at meal times, with help preparing food or with help in cleaning up after meals 2 Feeds self with moderate assistance and is untidy 1 Requires extensive assistance for all meals 0 Does not feed self at all and resists efforts of others to feed him 3. DRESSING 4 Dresses, undressed and selects clothes from own wardrobe 3 Dresses and undresses self, with minor assistance 2 Needs moderate assistance in dressing or selection of clothes 1 Needs major assistance in dressing but cooperated with efforts of other to help 0 Completely unable to dress self and resists efforts of others to help Value No 0 Value No 0

4. GROOMING 4 Always neatly dressed and well-groomed, without assistance 3 Grooms self adequately, with occasional minor assistance

Value No 0

2 Needs moderate and regular assistance or supervision in grooming 1Needs major assistance in dressing but cooperates with efforts of others to help 0 Actively negates all efforts to others to maintain grooming 5. PHYSICAL AMBULATION 4 Goes about grounds or city 3 Ambulates within residence or about one block distant 2 Ambulates with assistance of (check one): ____another person,___railing,____cane,_____ Value No 0

walker, or___wheelchair:____gets in and out without help___ needs help in getting in and out 1 Sits unsupported in chair or wheelchair, but cannot propel self without help 0 Bedridden more than half the time 6. BATHING 4 Bathes self (tub, shower, sponge bath) without help 3Bathes self, with help in getting in and out of tub 2Washes face and hands only, but cannot bathe rest of body 1 Does not wash self but is cooperative with those who bathe him 0 Does not travel at all 7. RESPONSIBILITY FOR OWN MEDICATION Value No 0 Value No 0

2 Is responsible for taking medication in correct dosages at correct time Takes responsibility if medication is prepared in advance in separate dosages 0 Does not try to wash self, and resists efforts to keep him clean TOTAL SCORE : 0

GERIATRIC ASSESSMENT CENTER SCALE FOR INSTRUMENTAL ACTIVITIES OF DAILY LIVING 1. ABILITY TO USE TELEPHONE 2 Dials a few well known numbers 1 Answers telephone but does not dial 0 Does not use telephone at all 2. SHOPPING 3 Takes care of all shopping needs independently Value No 0 Value No 0

3 Operates telephone on own initiative; looks up arid dials numbers, etc.

2 Shops independently for small purchases 1 Needs to be accompanied on any shopping trip 0 Needs to have meals prepared and served 3. FOOD PREPARATION 3 Plans, prepares and serves adequate meals independently 2 Prepares adequate meals if supplied with ingredients 1Heats and serves prepared meals, or prepares meals but does not maintain adequate diet 0 Needs to have meals prepared and served 4. HOUSE KEEPING 4Maintains house alone or with occasional assistance (e.g., heavy-work domestic help) 3 Performs light daily tasks such as dish-washing and bed-making 2Performs light daily tasks but cannot maintain acceptable level of cleanliness 1 Needs help with all home maintenance tasks 0 Does not participate in any housekeeping tasks Value No 0 Value No 0

5. LAUNDRY 2Does personal laundry completely Launders small items; rinses socks, stockings, etc. 0 All laundry must be done by others 6. MODE OF TRANSPORTATION

Value No 0

Value No 0

4 Travels independently on public transportation or drives own car 3Arranges own travel via taxi, but does not otherwise use public transportation 2 Travels on public transportation when assisted or accompanied by another 1 Travel limited to taxi or automobile, with assistance of another 0 Does not travel at all

7. RESPONSIBILITY OF OWN MEDICATION

Value No 0

2 Is responsible for taking medication in correct dosages at correct time 1 Takes responsibility if medication is prepared in advance in separate dosages 0 Is not capable of dispensing own medication 8. ABILITY TO HANDLE FINANCE bills, goes toBank) collects and keeps track of income 1 Manages day-to-day purchases, but needs help with banking, major purchases, etc. 0 Incapable of handling money TOTAL SCORE : 0 Value No 0

2 Manages financial matters independently (budgets, write checks, pays rent and