Geriatric Surgery Eligibility Verification Form
Please complete this form to assess whether an older adult patient is suitable for surgery. Ensure all information is accurate and relevant to the patient's current health status.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis
*
Major Comorbidities (Select all that apply)
Diabetes
Hypertension
Chronic Kidney Disease
Cardiac Disease
Pulmonary Disease
Other
Functional Status
*
Independent
Needs minimal assistance
Needs significant assistance
Bedbound
Cognitive Status
*
Normal
Mild impairment
Moderate impairment
Severe impairment
Frailty Assessment
*
Not frail
Mildly frail
Moderately frail
Severely frail
Surgical Risk Factors (Select all that apply)
High-risk cardiac history
Poor nutritional status
Recent hospitalizations
History of falls
Other
Is the patient currently taking any anticoagulant medications?
*
Yes
No
Summary of Surgical Eligibility (Clinical judgment)
*
Submit
Should be Empty: