Assessment Tool for Cultural/Ethnicities of Older Adults

By: Rhona Marie C. Noquiao, RN, MAN

A. Demographic Data

Name: Age:
Address: Civil Status:
Nationality: Religion:
Occupation: Educational Attainment:
Hobbies/Special Skills/Talents:
Organization/s Affiliated with:

B. Cultural Communication Tool:

-How would you like your name to be pronounced correctly?

-How would you like to be addressed?
-Are you amenable for this conversation? Yes___ No___

C. Cultural Perspectives on Family Obligations

-Who is tasked to be the decision-maker of the family in terms of:

a. health
b. household issues
c. education?
-What are your role assignments in your home? ( please check as many as applicable
to you)
___ breadwinner
___ head of the family
___homemaker
___ member

D. Cultural Perspectives on Personal Hygiene

-what is your idea of hygiene?(Please check as many as applicable to you)

____taking a bath Alone____Needing Assistance____

____brushing your teeth Alone____Needing Assistance____
____cutting your fingernails Alone____Needing Assistance____
____combing your hair Alone____Needing Assistance____
____wearing clean underwear & clothing Alone____Needing Assistance____
____others, pls. specify Alone____Needing Assistance____

E. Cultural Perspectives on Touch

- What is your idea of touch?

-Do you allow being touched when a medical assessment necessitates you to?
Yes___ No___
-How do you find yourself when being touched?
____cared
____healed
____comforted

F. Cultural Perspectives on Etiquette

-Are greetings/salutations important to you? Yes___ No ___ Why?

-Do values matter to you? Yes___ No ___ Why?

G. Cultural Perspectives on Clothing & Accessories

-Do you observe dress code? Yes___ No___ Why?

-How important does dressing properly to you?
-Are there specific dress codes you would like to have?

F. Cultural Perspectives on Diet/Nutrition

-What food preferences do you like best?

-What are the usual contents of your diet?
-How often do you eat in a day?
___once
___twice
___thrice
-How often do you take in-between meals?
___once
___twice
___thrice
J. Cultural Perspectives on Medical Interventions

- What is your understanding of the words medical interventions?

- Do you recognize the importance of medical interventions to health?
Yes____ No____Why?
-When sick/ill, who would you approach?
____Medical Doctor/Physician
____Quack Doctor
____Hilot
____Others, pls. specify
-Do you use herbal medicines? Yes____ No____
-Do you use synthetic medicines? Yes____ No____

-If a medical situation calls for, would you submit yourself to?
Blood transfusions Yes ____No____
Surgical operations Yes____No____
Organ transplantations Yes____No____

H. Cultural Perspectives on Sexuality

-how do you view yourself as being a man or a woman?

-do you still engage in intimacy with your partner? Yes___ No___
-what feeling does this intimacy brings to you?

I. Cultural Perspectives on Spirituality

-Would you briefly describe your personal spiritual beliefs; that is, do you believe in a
high power or Supreme Being or God? Yes____ No____
-How does your relationship with God support your life?
-Is there anything else you would like to share related to your perceptions or
experiences with your spiritual life?

Thank you.