Geriatric Care Management :: Assessment Form

Below is a sample of a form used by GCM Care Managers during an assessment of a new client:

Date of Contact:

Client Location

Client Name:
Address:

City: State: Zip:

Address of Assessment:

City: State: Zip:

Client History

Social History: Medical History: Educational/Vocational History: Mental Health History: Current Social Supports:

Functional Assessment

Medical Problem List:

Current Medications (name, dose and purpose):

Hospitalization/Surgery History: Special diet: Special Equipment or Therapy: Sensory/Expressive Impairment:

Auditory:
Visual:
Speech:

Functional Capabilities

Control of bowel and bladder:
Management of toileting at night:
Bathing:
Transferring bed, chair, toilet, etc.:
Dressing:
Eating:
Meal preparation:
Shopping:
Mobility:
Driving:
Assistive Devices:
Taking Medication:
Reaching light switches:
Home security:
Ability to use phone:
Housekeeping, laundry:
Managing home repairs:
Money management:
Ability to respond in emergency:

Home Safety Assessment

Carpeting and rugs:
Exposed pipes, radiators, cords:
Bath tub safety devices:
Adequate lighting:
Flooring:
Fire hazards:
Furniture:
Cane/walker safety:
Railings/grab bars:
Smoke alarms:
Posted emergency number:
Stove/cooking safety:
Access in/out of house:

Cognitive Function

Orientation: Short term memory: Long term memory: Language skills: Visual/spatial skills: Reasoning/Judgment: Insight: Executive Function: Motor Skills:

Psychological Function

Presentation/Appearance: Mood/Affect:
GDS Score:

Depression: -none -mild -moderate -severe

Anxiety: Psychotic Symptoms: Delusions: Hallucinations: Agitation: Behavioral Disturbance: Summary of Findings: