Older Care Form

An Older Care Form is an essential document that addresses the unique needs and preferences of elderly individuals in healthcare and caregiving settings. This comprehensive form allows seniors and their families to outline specific medical, living, and end-of-life preferences, ensuring that care providers understand and adhere to their wishes. By completing an Older Care Form, families can facilitate informed decision-making, enable personalized care plans, and establish a compassionate and dignified approach to supporting the health and well-being of older loved ones. This document serves as a valuable resource for healthcare professionals, ensuring that care aligns with the individual's values and desired quality of life.

CARE FOR OLDER ADULTS ASSESSMENT FORM

Preferred Location^*

Patient Assessment Date^*

Last Name^*

First Name^*

Date of Birth^*

FUNCTIONAL STATUS ASSESSMENT

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).