Comprehensive Geriatric Medical History Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: __________________
• Medicare/Insurance #: ______________________________

Primary Concerns

• Main reason for visit: _____________________________
• Duration of symptoms: ____________________________
• Previous treatment attempts: ______________________

Medical History

Chronic Conditions

• Hypertension
• Diabetes
• Heart Disease
• Arthritis
• COPD
• Other: _______________________________________

Previous Surgeries

1. Type: _________________ Date: _________________
2. Type: _________________ Date: _________________
3. Type: _________________ Date: _________________

Functional Assessment

Activities of Daily Living (ADL)

• Bathing: □ Independent □ Needs Help □ Dependent
• Dressing: □ Independent □ Needs Help □ Dependent
• Toileting: □ Independent □ Needs Help □ Dependent
• Mobility: □ Independent □ Uses Device □ Dependent

Cognitive Assessment

• Memory concerns: □ Yes □ No
• Confusion episodes: □ Yes □ No
• Previous cognitive testing: □ Yes □ No

Medication Review

Current Medications

1. Name: _________________ Dose: ________________
2. Name: _________________ Dose: ________________
3. Name: _________________ Dose: ________________

Allergies

• Medications: ___________________________________
• Other: _______________________________________

Social History

• Living Situation: □ Alone □ With Family □ Facility
• Primary Caregiver: _____________________________
• Fall History (past year): _________________________

Preventive Care

• Last Flu Shot: ________________________________
• Last Pneumonia Vaccine: _______________________
• Last Colonoscopy: ____________________________

Provider Notes

Authorization

Signature: _________________ Date: _____________