Comprehensive Geriatric Assessment Form

WNL = Within Normal Limits ASST = Assisted IND = Independent DEP = Dependent
○ Cognition □ WNL □ CIND □ MCI □ Dementia □ Delirium MMSE: ________ FAST: ________ ● Action Required

Chief lifelong occupation: _______________________________ Education (years): _______________ ○ Monitor

○ Emotional □ WNL □ ↓ Mood □ Depression □ Anxiety □ Fatigue □ Halluncination □ Delusion □ Other Patient contact:
□ Inpatient
○ Motivation □ High □ Usual □ Low Health Attitude □ Excellent □ Good □ Fair □ Poor □ Couldn't say □ Clinic
○ Communication Speech □ WNL □ Impaired Hearing □ WNL □ Impaired Vision □ WNL □ Impaired □ GDH
□ NH
○ Strength □ WNL □ Weak Upper: PROXIMAL DISTAL Lower: PROXIMAL DISTAL □ Outreach
○ Exercise □ Frequent □ Occassional □ Not □ Home
□ Assisted Living
○ Balance Balance WNL Impaired WNL Impaired
□ ER
Falls N Y Number ______ N Y Number ______
○ Mobility Walk Outside IND ASST Can't IND ASST Can't □ Other
Walking IND SLOW ASST DEP IND SLOW ASST DEP PT = PATIENT
CG = CAREGIVER
Transfers IND Stand by ASST DEP IND Stand by ASST DEP
Bed IND PULL ASST DEP IND PULL ASST DEP Current Frailty Score:
BASELINE (two weeks ago)

Aid None Cane Walker Chair None Cane Walker Chair Scale PT CG
○ Nutrition Weight GOOD UNDER OVER OBESE CURRENT (today) STABLE LOSS GAIN 1. Very fit
Appetite WNL FAIR POOR WNL FAIR POOR 2. Well
○ Elimination Bowel CONT CONSTIP INCONT CONT CONSTIP INCONT

NOTES
3. Well with Rx'd
Bladder CONT CATHETER INCONT CONT CATHETER INCONT co-morbid
○ ADLs Feeding IND ASST DEP IND ASST DEP disease
Bathing IND ASST DEP IND ASST DEP 4. Apparently
Dressing IND ASST DEP IND ASST DEP vulnerable
Toileting IND ASST DEP IND ASST DEP 5. Mildly frail
○ IADLs Cooking IND ASST DEP IND ASST DEP 6. Moderately
Cleaning IND ASST DEP IND ASST DEP frail
7. Severely
Shopping IND ASST DEP IND ASST DEP frail
Medications IND ASST DEP IND ASST DEP 8. Very
Driving IND ASST DEP IND ASST DEP severely frail
Banking IND ASST DEP IND ASST DEP 9a. Terminally
ill - walker
○ Sleep □ Normal □ Disrupted □ Daytime drowsiness Socially Engaged □ Frequent □ Occassional □ Not 9b. Terminally
ill - bed

○ Social □ Married Lives Home Supports Caregiver Relationship Caregiver Stress

□ Divorced □ Alone □ House (Levels___) □ Informal □ Spouse □ None
□ Widowed □ Spouse □ Steps (Number ___) □ HCNS □ Sibling □ Low
□ Single □ Other □ Apartment □ Other □ Offspring □ Moderate
ACTION REQUIRED (check appropriate circles)

□ Assisted Living □ Req. more support □ Other □ High

○ Advance directive □ Nursing home □ None Caregiver occupation (CG):
in place? □ Yes □ No □ Other ○ Code Status □ Do not resuscitate ______________________
□ Rescuscitate
Problems: Med adjust req. Associated Medication: (*mark meds started in hospital with an asterisk)
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Assessor/Physician:______________________________________ Date:____________________
(YYYY/MM/DD)
Assessment Forms
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