Geriatric Risk Assessment Questionnaire Form
Complete this questionnaire to help identify fall, mobility, medication, cognition, nutrition, and social-support concerns in an older adult.
Patient Overview
Age Group
*
65–69
70–74
75–79
80–84
85+
Primary Purpose for Assessment
*
Routine screening
Recent fall or injury
Memory or cognitive concerns
Medication review
Mobility or balance concerns
Other
Current Living Arrangement
*
Lives alone
Lives with spouse/partner
Lives with family
Assisted living
Independent living community
Skilled nursing facility
Other
Functional and Safety Screening
Mobility assistance needs
*
None
Occasional support
Regular assistance
Full assistance
Falls in the past 12 months
*
None
1 fall
2-3 falls
4 or more falls
Medication management difficulty
*
None
Mild
Moderate
Severe
Memory or confusion concerns
*
None
Mild
Moderate
Severe
Nutrition or appetite concern level
*
1
1
2
3
4
2
5
1 is , 5 is
Risk Summary and Follow-up
Overall concern areas
*
Rows
Low concern
Moderate concern
High concern
Falls
3
4
5
Mobility
6
7
8
Cognition
9
10
11
Medication management
12
13
14
Nutrition
15
16
17
Mood
18
19
20
Home safety
21
22
23
Additional notes / follow-up details
Submit Assessment
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