Care of Older Adults Worksheet - HMSA 2026

1. Click ‘Get Form’ to open the Care of Older Adults Worksheet - HMSA in the editor.
2. Begin by entering the patient’s name, date of birth, member ID number, and phone number in the designated fields at the top of the form.
3. In the Pain Assessment section, indicate whether pain is present by selecting 'Yes' or 'No'. Rate the current intensity of pain on a scale from 0 to 5 and specify if it is constant or limits daily activities.
4. Proceed to the Functional Status Assessment. Fill out ambulation status, vision, hearing, and speech conditions. Use checkboxes for each category and provide additional notes as necessary.
5. For Medication Review, enter the date and list medications along with their details. Ensure this section is completed by a prescribing provider or clinical pharmacist.
6. Complete the Advance Care Planning section by discussing treatment preferences and documenting any advanced directives. Make sure to note if discussions have occurred with family or caregivers.
7. Finally, have the provider print their name, sign, and date at the bottom of the form before saving a copy for your records.

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