Geriatric Cognitive Screening Intake Form
Patient Information
Full Name
Date of Birth
Age
Gender
Female
Male
Other
Contact Number
Address
Referral & Emergency Contact
Referred By
Emergency Contact
Emergency Phone
Medical History
Past & Current Medical Conditions
Current Medications
Allergies
Cognitive Concerns
Describe Cognitive Concerns (e.g., memory loss, confusion)
Onset & Duration of Symptoms
Impact on Daily Functioning
Psychiatric & Social History
Psychiatric History
Social History (e.g., living situation, support system)
Additional Notes