Geriatric Health Assessment Form

Geriatric Health Assessment Form — Form Fields

This healthcare template includes 8 fields. Comprehensive health assessment designed for older adults covering functional status, cognitive health, and social support. Supports coordinated geriatric care planning. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Age (number, required)
• How would you rate your overall health? (multiple choice, required) — options: Excellent, Good, Fair, Poor
• Activities of Daily Living — Do you need help with any of the following? (checkboxes, optional) — options: Bathing or dressing, Meal preparation, Managing medications, Transportation, Managing finances
• Have you fallen in the past 12 months? (multiple choice, required) — options: No, Yes — once, Yes — more than once
• Do you have someone to help you at home if needed? (multiple choice, required) — options: Yes — family member, Yes — paid caregiver, No — I live alone
• Have you noticed any memory or thinking changes recently? (multiple choice, optional) — options: No changes, Mild changes, Significant changes
• Biggest Health Concerns Right Now (long text, optional)