Geriatrics Intake Form
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Geriatrics Intake Form
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The Geriatrics Intake Form is purpose-built for geriatric medicine practices, capturing the multidimensional assessment that geriatricians need to provide comprehensive care for older adults. This template collects patient demographics alongside a thorough geriatric assessment covering activities of daily living (ADLs: bathing, dressing, toileting, transferring, feeding), instrumental activities of daily living (IADLs: medication management, finances, transportation, meal preparation, housekeeping), mobility and gait assessment, fall history and risk factors, sensory impairments (vision, hearing), nutritional status, and continence assessment. The cognitive screening section captures subjective memory concerns and is structured to complement in-office screening tools like the MMSE or MoCA.
Designed for geriatric medicine, senior care, memory care, and palliative medicine practices, this form includes sections for polypharmacy review (complete medication list with prescribing physician, indication, and potential deprescribing candidates), prior hospitalization and emergency department visits in the past year, chronic disease burden, pain assessment, mood screening (GDS-15 aligned), social support network, living situation and home safety, driving assessment, advance directive status (healthcare proxy, living will, POLST/MOLST), and caregiver identification with contact information and burden screening.
All fields are HIPAA-compliant and designed for the geriatric assessment workflow. The comprehensive format addresses the complexity of older adult care where multiple chronic conditions, functional limitations, and social factors intersect. Pre-visit completion by patients or their caregivers ensures that no critical domain is overlooked, and the structured format supports the development of individualized care plans that address medical, functional, cognitive, and psychosocial needs.
What's included
- ADL and IADL functional assessment
- Fall risk screening and mobility evaluation
- Cognitive and mood screening questionnaires
- Medications list with polypharmacy review and deprescribing assessment
- Advance directive and healthcare proxy documentation
- Consent agreement with caregiver identification and support needs
- Structured medication list with dosage and frequency tracking
Who uses this template
- Geriatric medicine and senior primary care practices
- Memory care and cognitive assessment clinics
- Senior wellness and fall prevention programs
- Palliative care and advance care planning services
All form fields
17 fields across 4 pages. Customize any field after signing up.
How to use the Geriatrics Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Geriatrics Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Geriatrics Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 17 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Geriatrics Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Geriatrics Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 17 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Geriatrics Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Geriatrics Intake Form for your practice. Set up in minutes.
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