Geriatric Specialty Care Plan
Complete this form to document a comprehensive care plan for geriatric patients, including assessments, goals, interventions, and responsible team members.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Diagnosis
*
Comorbidities (select all that apply)
Diabetes
Hypertension
Dementia
Heart Disease
Arthritis
Other
Functional and Cognitive Assessment
*
Rows
Independent
Needs Assistance
Dependent
Mobility
1
2
3
Feeding
4
5
6
Dressing
7
8
9
Bathing
10
11
12
Toileting
13
14
15
Memory
16
17
18
Orientation
19
20
21
Current Medications (list all)
Allergies
Care Goals (patient/family preferences)
*
Planned Interventions
*
Responsible Care Team Member
Next Follow-Up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Patient or Authorized Representative
*
Submit Care Plan
Submit Care Plan
Should be Empty: