COMPREHENSIVE GERIATRIC ASSESSMENT

Patient: [Name, age, date of birth]
Date and setting: [Date; geriatric clinic, primary care, home visit, day hospital, or hospital ward]
Present: [Patient, family member or caregiver, interpreter]
Sources: [Patient, caregiver, medicine bottles, pharmacy record, previous notes]
Clinician and team: [Name, credentials; nurse, pharmacist, therapist, or social worker involved]

REASON AND GOALS
Referral question: [Who referred, and what they asked]
Goals: [What matters most, in the patient's words; the caregiver's main concern]

MEDICAL PROBLEMS
Active conditions: [Each condition, how well controlled, recent changes]
Recent events: [Hospital stays, emergency visits, new symptoms in the past 6 months]
Examination: [Lying and standing BP and pulse, weight and height, focused findings]
Recent tests: [Bloods, ECG, imaging, with dates and results]

MEDICATION REVIEW
Every medicine: [Prescription, over-the-counter, and herbal products, with dose; the total]
Who manages them: [Self, family, organizer, blister pack; missed doses]
Medicines flagged: [Each one, the criteria used, Beers or STOPP, and why]
Missing treatment: [Indicated but not prescribed, by START criteria or your judgment]
Deprescribing plan: [What stops or tapers, in what order, what to watch for, and when to recheck]

FUNCTION AND MOBILITY
Basic activities: [Katz ADL score out of 6, and the activities that need help]
Instrumental activities: [Lawton IADL score out of 8, who does each task lost, and what the patient managed a year ago]
Falls in the past year: [Number, what happened just before, injuries, time on the floor]
Timed Up and Go: [Seconds and walking aid; rising, turning, reaching for support; fear of falling]

COGNITION AND MOOD
Testing conditions: [Glasses and hearing aids in, quiet room, language or interpreter]
Cognitive screen: [Mini-Cog out of 5, MoCA out of 30 with years of schooling, or another tool]
Delirium: [Sudden change or attention that comes and goes, or none]
Mood screen: [GDS-15 out of 15, and what the interview added]
Thoughts of death or suicide: [Asked directly; the answer; means at home]

NUTRITION, CONTINENCE, VISION AND HEARING
Weight change: [Today's weight, an earlier weight with its date, and the percentage change]
Intake and teeth: [Meals, who shops and cooks, appetite, alcohol, dentures and their fit]
Bladder and bowel: [Urgency, leaks, night trips, pads, constipation, and when each began]
Vision: [Acuity with glasses, type of lenses, last eye exam]
Hearing: [Whispered voice test or report, hearing aids, ear canals]

FRAILTY AND SUPPORT
Frailty level: [Clinical Frailty Scale level 1 to 9 on the baseline, or Edmonton Frail Scale total out of 17]
Living situation: [Alone or with whom; type of home; stairs]
Supports and caregiver: [Family, friends, paid help; the caregiver's help each week, health, and strain]
Money and mistreatment: [Money worries; asked alone about neglect or mistreatment]

HOME SAFETY AND ADVANCE CARE PLANNING
Home: [Lighting, rugs, stairs and rails, bathroom, stove, personal alarm]
Driving and firearms: [Drives or not, and any concerns; firearms and how they are stored]
Decision-maker: [Name, relationship, and documents on file]
Wishes: [Goals of care and treatment wishes discussed, or the date booked]

PROBLEM LIST AND PLAN
Problems by domain: [Each problem, the domain it came from, the plan, who acts, and by when]
Referrals: [Physical therapy, occupational therapy, dietitian, audiology, memory clinic, social work]
Shared with: [Patient, caregiver, referring clinician, care team]
Follow-up: [Date, and what will be rechecked]

Signed: [Clinician name, credentials, date]