Geriatric Oncology Assessment Form

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
Patient Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Age
Sex at Birth / Gender Identity (if needed for care)
Prefer to self-describe
Preferred Contact Method
Other
Date of Assessment
MonthDayYear
Date
Referring Clinician / Department
Primary Oncology Diagnosis or Reason for Referral
Cancer and Treatment History
Cancer Type / Site
Stage / Disease Status
Date of Diagnosis
MonthDayYear
Date
Current Treatment Phase
Prior Treatments Received
Other
Treatment-Related Complications or Intolerances
Current Symptoms and Toxicity Review

Symptom burden over the past 1–2 weeks

Rows	None	Mild	Moderate	Severe
Fatigue
Pain
Nausea/vomiting
Appetite loss
Weight loss
Constipation
Diarrhea
Neuropathy
Shortness of breath
Dizziness/falls
Sleep disturbance
Confusion/memory concerns

Most concerning symptom and any acute issues
Overall symptom burden
Geriatric Function and Frailty
Activities of Daily Living (ADLs)
Rows Independent Needs Assistance Dependent
Bathing
Dressing
Toileting
Transferring
Feeding
Continence
Instrumental Activities of Daily Living (IADLs)
Rows Independent Needs Assistance Dependent
Shopping
Cooking
Managing Medications
Managing Finances
Transportation
Falls in the Past 12 Months
Number of Falls
Use of Mobility Aid
Other
Overall Frailty / Performance Status

1
2
3
4
5
6
7
8
9
10
1 is Fully active, 10 is Severely frail
Comorbidities, Medications, and Support
Major comorbid conditions
Other
Current medications
Allergies and reactions
Nutritional concerns
Other
Recent unintentional weight change (pounds)
Social support / caregiver availability
Other
Living situation
Other
Advanced care needs or barriers to care
Clinician Assessment and Plan
Overall Geriatric Oncology Risk Summary
Key Vulnerabilities or Concerns
Other
Recommendations for Further Evaluation or Referrals
Other
Follow-Up Date
MonthDayYear
Date
Plan / Notes
Should be Empty:

Select theme: