About this template
A mental capacity assessment form is utilized by physicians, nurses, psychologists, and social workers to formally evaluate a patient's ability to make informed healthcare or legal decisions. This structured digital template helps clinicians systematically record cognitive status, understanding of medical options, ability to retain and weigh information, and communication methods.
Designed for use in hospitals, clinics, and long-term care facilities, this form ensures a standardized approach when assessing individuals experiencing cognitive decline, dementia, acute mental illness, or other forms of impairment. By capturing critical clinical notes, advanced directives, and best-interests determinations in one organized record, care teams can maintain clear documentation and support ethical, patient-centered decision-making.
Key features
- Standardize clinical evaluations with a structured, step-by-step format
- Record cognitive impairment status and decision-making criteria clearly
- Document advanced directives and communication methods instantly
- Securely attach supporting documents via Google Drive links
- Export assessment data directly to Google Sheets for clinical tracking
Use cases
- Hospital admissions and discharge planning for elderly patients
- Capacity evaluations prior to complex medical procedures
- Long-term care placement and guardianship assessments
- Mental health evaluations involving cognitive impairment
What this form collects
- Assessment Date (Date)Select the date the evaluation was conducted.
- Assessment Location (Short answer)Enter the hospital, clinic, or facility name and room number.
- Patient Full Name (Short answer)Enter the first and last name of the patient.
- Patient Date of Birth (Date)Enter the patient's date of birth.
- Patient Gender (Dropdown)Select the patient's gender.
- Patient Address & Contact Number (Paragraph)Provide the patient's primary residential address and contact phone number.
- Clinician Name & Role (Short answer)Enter your full name and professional title (e.g., Dr. Jane Doe, Psychiatrist).
- Reason for Assessment (Paragraph)Describe the specific decision or situation prompting this mental capacity assessment.
- Clinical Grade / Severity (Multiple choice)Indicate the severity level observed during the evaluation.
- Brain or Mind Impairment Status (Multiple choice)Is there an established or suspected impairment of the mind or brain?
- Impairment and Disturbance Details (Paragraph)Provide details regarding the nature of the cognitive impairment or disturbance.
- Understanding Decision Information (Multiple choice)Can the patient understand the information relevant to the decision?
- Retaining Decision Information (Multiple choice)Can the patient retain the information long enough to make the decision?
- Using Information for Informed Decision (Multiple choice)Can the patient use or weigh that information as part of the decision-making process?
- Communicating the Decision (Multiple choice)Can the patient communicate their decision (by talking, sign language, or other means)?
- Communication Method (Checkboxes)Select the primary method used by the patient to communicate.
- Advanced Directive Status (Multiple choice)Does the patient have an existing advanced directive, living will, or designated proxy?
- Advanced Directive Details (Paragraph)Provide summary details regarding the advanced directive or designated proxy agent.
- Advanced Directive Document Link (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
- Best-Interests Actions (Paragraph)If capacity is lacking, outline the recommended actions to be taken in the patient's best interests.
- Discharge and Care Plan (Paragraph)Summarize the immediate care plan or discharge recommendations based on this assessment.
- Clinician Sign-off & Notes (Paragraph)Enter any final clinical observations, recommendations, or confirmation of assessment completion.
FAQ
Who is qualified to fill out this mental capacity assessment?
This form is intended for licensed healthcare professionals, including medical doctors, registered nurses, psychologists, psychiatrists, and clinical social workers.
Can I customize the questions in this Google Form template?
Yes! Once you open the template in Google Forms, you can fully edit, add, or remove any questions to align with your facility's specific clinical guidelines.
How do I handle document attachments like advanced directives?
The form includes a dedicated upload prompt where respondents can paste links to securely stored files in Google Drive, Dropbox, or other cloud storage systems.
Where is the assessment data stored?
All submitted assessments are saved securely in your Google Drive and automatically populated into a linked Google Sheets spreadsheet for easy review.
Is this template free to use?
Yes, this template is completely free to copy, customize, and deploy using Doc2Form and Google Forms.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.