• Geriatric Oncology Assessment Form

    Use this form to assess an older adult cancer patient’s oncology history, symptoms, function, comorbidities, and care needs for clinical planning.

  • Patient and Encounter Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex at Birth / Gender Identity (if needed for care)
  • Preferred Contact Method*
  • Date of Assessment*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Cancer and Treatment History

  • Date of Diagnosis
     - -
    2 digit month, 2 digit day, 4 digit year
  • Prior Treatments Received

  • Current Symptoms and Toxicity Review

  • Symptom burden over the past 1–2 weeks*
    Rows

  • Geriatric Function and Frailty

  • Activities of Daily Living (ADLs)*
    Rows
  • Instrumental Activities of Daily Living (IADLs)*
    Rows
  • Falls in the Past 12 Months*
  • Use of Mobility Aid

  • Comorbidities, Medications, and Support

  • Major comorbid conditions
  • Current medications
  • Nutritional concerns
  • Social support / caregiver availability
  • Living situation

  • Clinician Assessment and Plan

  • Key Vulnerabilities or Concerns
  • Recommendations for Further Evaluation or Referrals
  • Follow-Up Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty:
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