Geriatric Comprehensive History

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History provided by ***Self/Spouse/Child/Other***
Language: ***English/Spanish/Other***
Marital History: ***Married/Widowed/Divorced/Single***
Resident lives ***at home/at apartment/at skilled nursing home/at assisted living/with family member/at adult foster care***.
Past Medical/Surgical History:  ******
Mental Health
***Geriatric Depression Score***
***Mini Mental Status Exam***
Number of Previous Admissions: ******
Current Medications: ***Name, dose, frequency, dx***
Review all medications for important interactions:  ******
Special Dietary needs:
a) Loss of 10 pounds in last 6 months ***Yes/No***
b) Is referral to dietician indicated ***Yes/No***
Special Equipment or Therapy:  ******
13. Sensory/Expressive Impairment:
a) Hearing (last hearing test) ******
b) Visual (last eye exam) ******
Bladder: ***Continent/Incontinent***
Bowel: ***Continent/Incontinent***
Activities of Daily Living: Needs Help
a) Bathing ***Yes/No***
b) Transferring ***Yes/No***
c) Dressing ***Yes/No***
d) Cooking ***Yes/No***
e) Shopping ***Yes/No***
f) Driving ***Yes/No***
g) Taking medications ***Yes/No***
h) Reaching light switches ***Yes/No***
i) Home security ***Yes/No***
j) Ability to use phone ***Yes/No***
k) Housekeeping ***Yes/No***
l) Laundry ***Yes/No***
m) Home repairs ***Yes/No***
n) Money management (finances) ***Yes/No***
o) Ability to respond in emergency ***Yes/No***
Someone in the household able to assist ***Yes/No***
Mobility: Balance/Mobility
Use of device: Yes or No
Get up & go test ***Positive/Negative***
(Pos > 16 seconds) (Rise from chair, walk 10 feet, turns and returns to chair to sit)
History of falls ***Yes/No***
Skin Integrity:
Skin breakdown: ***Yes/No***
Wound care/education needed ***Yes/No***
Sleep Disorders: Yes or No
Substance Abuse:
ETOH ***Yes/No***
Drugs ***Yes/No***
Overuse Narcotics ***Yes/No***
Tobacco ***Yes/No***
Immunizations:
Tetanus: ***Yes/No***
Influenza ***Yes/No***
Pneumococcal ***Yes/No***
Educational/Vocational History:  ******
Social Supports:  ******
Living Will: ***Yes/No***
Power of Attorney for Health Care: ***Yes/No***
Power of Attorney for Finances: ***Yes/No***
Code Status: ***Full Code/DNR-DNI/DNR-DNI (hospitalize as necessary)/DNR-DNI (comfort care)/Hospice***
Spiritual Needs:
Referral Needs: OT ***Yes/No***
PT ***Yes/No***
Speech ***Yes/No***
Social Services ***Yes/No***
Home Health Care ***Yes/No***
Plan of Care/Recommendations:  ******

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Geriatric Comprehensive History

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