Older Care Form

Older Care Form in Bronx By NYCDocs is a crucial document for the older people of the community. We are committed to meet your individualized requirements. We prioritize your comfort and well-being. The geriatric care form in Bronx is designed to collect your essential medical data. Your medical history and medication information is needed. We care for your specific concerns. We maintain your privacy and confidentiality with the standard of HIPAA consent form. We appreciate your trust in NYCDocs in Bronx, NYC.

CARE FOR OLDER ADULTS ASSESSMENT FORM

Preferred Location^*

Patient Assessment Date^*

Last Name^*

First Name^*

Date of Birth^*

FUNCTIONAL STATUS ASSESSMENT

Activities of Daily Living

ADVANCE CARE PLANNING

Have you discussed with your doctor what would happen if you are unable to make your own medical decisions? Yes No

Check all advance care planning you have in place:

Advanced Directives Living Will Actionable Medical Orders

MEDICATION REVIEW

Are you on any Medication(s): Yes No

Medication Name	Medication Name	Medication Name

PAIN ASSESSMENT

Do you have pain? Yes No

Advance Care Planning Key

Advanced Directive: Living will, power of attorney, health care proxy.

Actionable Medical Orders: Physician orders for Life Sustaining Treatment [POLST], Five Wishes.

Living will: Legal document denoting preferences for life-sustaining treatment and end-of-life care

^* I acknowledge that this form will be reviewed by the provider and will be placed into the physical medical record and/or scanned into the Electronic Health Record (EMR).

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Older Care Form

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