Free Geriatric Intake Assessment Template

What is a geriatric intake assessment?

A geriatric intake assessment is a specialized comprehensive evaluation designed for older adult clients, typically age 65 and above. Unlike standard adult intakes, geriatric assessments emphasize cognitive and medical complexity, functional decline, social isolation, end-of-life concerns, and medication management. Older adults often present with multiple comorbid medical conditions, polypharmacy (five or more medications), cognitive changes that may be age-normal or early dementia, grief from multiple losses, and unique psychosocial stressors related to aging. A thorough geriatric intake evaluates cognitive status using validated screening tools (Montreal Cognitive Assessment, Mini-Cog), reviews all medications for interactions and deprescribing opportunities, assesses functional ability (activities of daily living and instrumental activities of daily living), examines social support and isolation risk, and explores existential and end-of-life concerns. The assessment also involves coordination with primary care and other specialists treating the older adult.

What's in this template

This geriatric-specific intake assessment includes:

• Identifying Information & Chief Concerns: Client demographics, living situation, referral source, self-identified vs. family-identified concerns
• Cognitive Screening: Results from Mini-Cog, Montreal Cognitive Assessment (MoCA), or other brief cognitive tools; subjective memory complaints; family observations of cognitive changes
• Medical History & Comorbidities: Chronic conditions, surgeries, hospitalizations, falls history, sensory changes (hearing, vision), sleep disorders, incontinence
• Current Medications & Supplements: Complete medication list (prescription, over-the-counter, supplements), dosages, adherence, and assessment for polypharmacy or drug interactions requiring primary care coordination
• Functional Status: Activities of daily living (bathing, dressing, toileting, continence, feeding, mobility) and instrumental ADLs (managing medications, finances, cooking, housework, shopping, transportation); any assistive devices or home modifications
• Mental Health History: Past psychiatric diagnoses, depression screening (PHQ-9 or GDS), anxiety, substance use history, past suicide attempts or current suicidal ideation
• Social History & Support System: Living arrangement, family involvement and proximity, friendships/social activities, volunteer roles, financial security, grief history and recent losses
• Hearing & Vision: Formal or informal assessment of sensory abilities; use of hearing aids or glasses; impact on communication and safety
• Advance Planning: Living will or healthcare proxy documentation, code status preferences, goals of care, spiritual or religious preferences, family meetings completed or needed
• Substance Use & Alcohol: Current and past use, changes in use patterns, assessment for dependence
• Safety Factors: Fall risk, medication adherence risk, financial exploitation or scams, caregiver burnout, driving safety concerns
• Nutritional & Sleep Status: Weight changes, appetite, swallowing difficulties, insomnia, sleep apnea, daytime somnolence
• Sexual Health & Intimacy: Current relationship status, sexual activity, concerns about sexual function related to medications or age
• Strengths & Resilience: Coping skills, meaning and purpose in life, spiritual practice, long-standing interests and activities, pride in accomplishments

When to use this template

Use the geriatric intake assessment when:

• Opening treatment with an older adult client (typically age 65+)
• Conducting comprehensive diagnostic evaluations for older adults presenting with depression, anxiety, grief, or cognitive concerns
• Establishing baseline cognitive and functional status
• Assessing polypharmacy and need for medication coordination with primary care
• Evaluating end-of-life planning needs and capacity for medical decision-making
• Addressing social isolation, caregiver stress, or existential concerns related to aging

This template is appropriate across settings: private practice, geriatric psychiatric clinics, medical practices, nursing homes, senior centers, and adult day programs.

How to use the template with Scriber

Record your geriatric intake session with consent and Scriber transcribes the full interview, capturing detailed medication lists, functional descriptions, family relationships, and end-of-life discussion. Rather than struggling to document complex medical histories or trying to remember all medications mentioned, you have a transcript to reference. Edit the AI-generated draft to ensure medications and dosages are accurate, add observations about cognition and affect you assessed during the interview, refine the formulation considering the older adult's strengths and life history, and organize findings into the geriatric assessment framework. This approach preserves your clinical focus on the client while AI handles the documentation burden — particularly valuable in geriatric work where comprehensive assessment is essential but time-consuming.

Download (free)

This template is available as a printable PDF and editable DOCX file. Adapt it to your setting and approach, remove or add sections as needed, and use it as a standard form for all geriatric intakes.

[Download PDF]

Related templates

• Child Intake Assessment — Specialized intake for children and adolescents emphasizing developmental history and parent input
• SOAP Note Template — Standard progress note format for documenting ongoing work with older adult clients