Geriatric Assessment Form (GAF)
UNC Geriatric Evaluation and Management Clinic
Name:
Appointment with:
DOB:
Age:
Date and time of appointment:
Gender:
Race:
Source of information:
MR#: Phone:
Date of phone call:
Address:
Primary care provider:
Interviewer:
Referral from:
Reason for referral
History of Present Illness
Past Medical History
1.
2.
3.
4.
5.
Past Surgical History
Mental Health
Sleep disorder
Health Maintenance
 Influenza
 Tetanus
 Pneumovax
 Mammogram
 BMD
 Colonoscopy
How Does Patient Pay for Medications?
Allergies/Adverse Events:
6.
7.
8.
9.
10.
Current Medications (including OTCs/herbals)
Pertinent Past Medications (per patient or record)
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
7.
7.
8.
8.
9.
9.
10.
10.
11.
11.
12.
12.
Family History
 Mother

Father
Disease
 Dementia
 CAD
 HTN
 CVA
 DM
 Osteoporosis
 Cancer
 Depression
 Psychiatric illness
 Others (of note)
Family member
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:
Age of onset
ADL
Bathing
Dressing
Toileting
Transferring
Bowel
Bladder
Feeding
Not Able
With Help
Able
IADL
Uses telephone
Grocery shopping
Prepare meals
Housework
Laundry
Takes own medicine
Personal finances
Not Able
With Help
Memory check list
Problem Present
Comments
Problem Present
Comments
Forgetfulness (in general)
Remembering names
Remembering messages
Remembering the date
Job performance
Driving
Speech
Home safety
Social withdrawal
Getting lost
Personality changes
Behavioral observation
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
Able
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)