Allergies/Intolerances: Pharmacy information: *Include NSAIDS, OTC’s, Vitamins, Herbals, creams, eye drops, and inhalers * for PRN’s include frequency and efficacy * for other medications include the duration of use, efficacy, and date of dosage changes *Include hospitalizations/ diagnosis * Include name of specialists/ date last assessment Height: Weight: BMI:
Allergies/Intolerances: Pharmacy information: *Include NSAIDS, OTC’s, Vitamins, Herbals, creams, eye drops, and inhalers * for PRN’s include frequency and efficacy * for other medications include the duration of use, efficacy, and date of dosage changes *Include hospitalizations/ diagnosis * Include name of specialists/ date last assessment Height: Weight: BMI:
Comprehensive%20Geriatric%20Assessment%20paper%20(21).docx