Geriatric Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Contact Number
Address
Emergency Contact Name & Number
Medical History
Current Medications
Allergies (medications, food, etc.)
Chronic Conditions (e.g. diabetes, hypertension)
Previous Surgeries or Hospitalizations
Family Medical History
Immunization Status
Functional Assessment
Any difficulties with Activities of Daily Living?
None
Some
Significant
Mobility Issues
Vision or Hearing Problems
Use of Assistive Devices (e.g. walker, hearing aid)
Lifestyle & Other Information
Diet
Exercise & Physical Activity
Tobacco/Alcohol Use
Additional Notes/Comments