Geriatric Patient Intake Form
Full Name
Date of Birth
Age
Gender
Female
Male
Other
Marital Status
Single
Married
Widowed
Divorced
Other
Preferred Language
Contact Information
Phone
Email
Address
Emergency Contact
Emergency Contact Name
Relationship
Contact Number
Medical History
List any current medical conditions
Past Surgeries/Hospitalizations
Current Medications
Allergies
Functional Status
Can you independently perform the following? (Check if yes)
Bathing
Dressing
Toileting
Feeding
Transferring
Walking
Cooking
Managing Finances
Social History
Living Situation
Alone
With Family
Assisted Living
Other
Primary Caregiver
Other Concerns/Comments