Geriatric Home Healthcare Assessment Form
Patient Name
Date of Birth
Assessment Date
Gender
Male
Female
Other
Contact Number
Address
Primary Caregiver
Relationship to Patient
Contact Information (Caregiver)
Medical History
Current Medications
Allergies
Functional Status
Ambulation
Independent
With Assistive Device
Needs Assistance
Bedbound
Vision
Normal
Impaired
Blind
Hearing
Normal
Impaired
Deaf
Speech
Normal
Impaired
Nonverbal
Feeding
Independent
Needs Assistance
Tube Fed
Cognitive Status / Mental Health
Social Support & Living Arrangements
Risk Factors (e.g., falls, pressure ulcers)
Nutritional Status
Other Notes & Observations