Senior Health Risk Screening
Patient Information
Full Name
Age
Date of Birth
Gender
Female
Male
Other
Contact Number
Address
Medical History
Chronic Conditions
Current Medications
Allergies
Functional Assessment
Assistance Required
ADL
Mobility
Feeding
Toileting
Other
If Other, specify
History of Falls in Past Year
Yes
No
If Yes, Number of Falls/Details
Lifestyle & Screening
Smoking Status
Never
Former
Current
Alcohol Use
Never
Occasionally
Regularly
Last Preventive Screening
Cognitive/Mental Health
Cognitive Concerns
Mood/Depression Concerns
Social Support
Primary Caregiver
Social Support/Resources
Notes/Recommendations