Geriatric Pre-Op Risk Assessment
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Medical Record #
Surgical Procedure
Comorbidities
List all relevant comorbidities and chronic conditions
Functional Status
Describe current functional status (ADLs, mobility, etc.)
Cognitive Assessment
Brief cognitive screen (MMSE, MOCA, etc.) or comments
Medication Review
List current medications
Social Support / Living Situation
Nutritional Status
Frailty Assessment
Method / Results
Risk Stratification
ASA, cardiac risk, other assessment tools
Advance Directives / Goals of Care
Overall Impression & Recommendations