Elderly Care Assessment Template
Personal Details
Full Name
Date of Birth
Gender
Male
Female
Other
Address
Phone
Emergency Contact
Medical History
Medical Conditions
Allergies
Current Medications
Functional Assessment
Mobility Status
Independent
Needs Assistance
Bedridden
Activities of Daily Living (ADL)
Aid Devices Used
Cognitive & Emotional Status
Cognitive Status
Alert
Confused
Dementia
Other
Emotional Health
Nutrition & Hydration
Dietary Requirements
Hydration Concerns
Social & Family Support
Social Support
Family Involvement
Safety Assessment
Safety Concerns
Home Hazards
Additional Notes