Geriatrics Intake Form

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.