Program on Aging

Geriatric Assessment Form (GAF)

UNC Geriatric Evaluation and Management Clinic

Name: DOB: Age:

Gender: Race:

MR#: Phone: Address: Interviewer: Appointment with: Date and time of appointment: Source of information:

Date of phone call: Primary care provider:

Referral from:

Reason for referral

History of Present Illness

Past Medical History1.

2.

3.

4.

5. 6.

7.

8.9.10.

Past Surgical HistoryMental Health

Sleep disorder

Health Maintenance

Influenza

Tetanus

Pneumovax

Mammogram

BMD

Colonoscopy How Does Patient Pay for Medications?

Allergies/Adverse Events: Current Medications (including OTCs/herbals)1.

2.3.4.5.6.7.8.9.10.11.12.Pertinent Past Medications (per patient or record)1.2.3.4.5.6.7.8.9.10.11.12.

Family History

Mother Father

Disease

Family member

Age of onset Dementia

CAD

HTN

CVA

DM

Osteoporosis

Cancer

Depression

Psychiatric illness

Others (of note)

Social History Activities/Exercise - ETOH - Tobacco - Years of education - Job history/retirement -

Number of Siblings - Number of Children - Marital status - Planning Power of attorney -

Health Care Power of Attorney -

Advanced Directives -

Placement options -

Assistive devices:

ADLNot AbleWith HelpAbleIADLNot AbleWith HelpAble

BathingUses telephone

DressingGrocery shopping

ToiletingPrepare meals

TransferringHousework

BowelLaundry

BladderTakes own medicine

FeedingPersonal finances

Memory check list

Problem PresentComments

Forgetfulness (in general)

Remembering names

Remembering messages

Remembering the date

Job performance

Driving

Speech

Home safety

Social withdrawal

Getting lost

Personality changes

Behavioral observation

Problem PresentComments

Behavior problems (in general)

Psychomotor

Anxious

Agitated

Irritable

Aggressive

Stereotyped vocalization/screaming

Tearful

Impulsive

Restless

Suspicious

Resistance to care

Wandering

Hallucinations

Disciplines to see patient in addition to geriatrician. List primary problem warranting referral.

SW

PT

OT

Psych

Pharmacy

Neurology

Laboratory Data

Date

BP

P

Wt

Ht

Na

K

Cl

CO2

BUN

SCr

Estimated CrCl

Glucose

Calcium

Phosphorous

Magnesium

AST

ALT

Alk Phos

Tot bili

Prot/Alb

Cholesterol

LDL

HDL

Triglycerides

Non-HDL Chol

HgA1c

PSA

TSH

MCV

Fe

Folate

B12

WBC

Hgb

Hct

Plt

PT/PTT

25-OH Vit D

Notes

Problem list (with preliminary assessment and plan)