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Geriatric Health Assessment Form - Free Healthcare Template | ZenBuild | ZenBuild

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Geriatric Health Assessment Form

Comprehensive health assessment designed for older adults covering functional status, cognitive health, and social support. Supports coordinated geriatric care planning.

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Geriatric Health Assessment Form

This assessment helps us understand your overall health and functional needs as we plan your care.

Patient Name*

Age*

How would you rate your overall health?*

ExcellentGoodFairPoor

Activities of Daily Living — Do you need help with any of the following?

Bathing or dressingMeal preparationManaging medicationsTransportationManaging finances

Have you fallen in the past 12 months?*

NoYes — onceYes — more than once

Do you have someone to help you at home if needed?*

Yes — family memberYes — paid caregiverNo — I live alone

Have you noticed any memory or thinking changes recently?

No changesMild changesSignificant changes

Biggest Health Concerns Right Now

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

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healthcaregeriatricselderly caresenior healthfunctional assessment