Geriatric Assessment Health Evaluation
Please complete this form to help us evaluate your overall health and well-being.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Phone
*
Current Living Situation
*
Alone
With family
Assisted living
Nursing home
Other
Activities of Daily Living (ADL) Assessment
*
Rows
Independent
Needs Assistance
Dependent
Bathing
1
2
3
Dressing
4
5
6
Toileting
7
8
9
Transferring
10
11
12
Feeding
13
14
15
Continence
16
17
18
Cognitive Status (Memory and Orientation)
*
No issues
Occasional forgetfulness
Frequent memory problems
Disoriented/confused
Mood Assessment (Depression Screening)
*
No signs of depression
Occasional sadness
Persistent sadness or loss of interest
Mobility and Fall Risk
*
Walks independently
Uses cane/walker
Wheelchair-bound
History of falls in the past year
Current Medications (List all, including over-the-counter and supplements)
*
Chronic Medical Conditions (Select all that apply)
*
Hypertension
Diabetes
Heart disease
Arthritis
Osteoporosis
Respiratory disease
Vision impairment
Hearing impairment
Other
Nutrition Status (Have you unintentionally lost weight in the last 6 months?)
*
No
Yes, less than 5kg
Yes, 5kg or more
Social Support (Do you have someone to help you if needed?)
*
Yes, always
Sometimes
No
Signature
*
Submit Assessment
Submit Assessment
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