Elderly Patient Health Risk Assessment
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Contact Number
Medical History
Chronic Conditions
Medications
Allergies
Assessment
Recent Hospitalizations
Mobility Status
Independent
Uses Assistive Device
Requires Assistance
Bedbound
Fall History (past year)
None
1
More than 1
Cognitive Assessment
Lifestyle & Social
Living Situation
Alone
With Family
Assisted Living
Nursing Home
Support System
Lifestyle Factors
Comments / Notes