FRAIL SCALE RISK ASSESSMENT

Question Scoring Result

F FATIGUE
How much of the time during the past 4 weeks did you feel tired?
A=1
A = All or most of the time
B=0
B = Some, a little on none of the time
R RESISTANCE
In the last 4 weeks by yourself and not using aids, do you have any difficulty walking up YES = 1
10 steps without resting? NO = 0
A AMBULATION
In the last 4 weeks by yourself and not using aids, do you have any difficulty walking 300 YES = 1
meters or one block? NO = 0
I ILLNESS
Did your doctor ever tell you that you have?
 Hypertension
 Diabetes
 Cancer (not a minor skin cancer)
0 – 4 answers/
 Heart attack
=0
 Congestive heart failure
 Angina
5 – 11 answers/
 Asthma =1
 Arthritis
 Kidney disease
L LOSS OF WEIGHT YES = 1
Have you lost more than 5kg or 6% of your body weight in the past year? NO = 0
TOTAL SCORE
SCORING: ROBUST = 0 PRE-FRAIL = 1-2 FRAIL = >3

PATIENT HEALTH QUESTIONNAIRE - 9

Over the last 2 weeks, how often have you been bothered by any of the following More Nearly
Not Several
problems? than half every
at all days
the days day
1. Little interest or pleasure on doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself – or that you are a failure or have let yourself or your 0 1 2 3
family down
7. Trouble concentrating on things, such as reading the newspaper or watching 0 1 2 3
television
8. Moving or speaking so slowly that other people could have noticed? Or the 0 1 2 3
opposite – being so fidgety or restless that you have been moving around a lot
more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3
If you checked off any problems, how difficult have theses problems made it for you FOR OFFICE CODING
to do your work, take care of things at home, or get along with other people? __0___+_______+_______ + ______
Not difficult Somewhat Very Extremely
at all difficult difficult difficult = Total score: _______
   
Last Name: First name:
Sex: Age: Weight, kg: Height, cm: Date:
Complete the screen by filling on the boxes with the appropriate numbers. Total the numbers for the final screening score.
NUTRITION ASSESSMENT SCREENING
Has food intake declined over the past 3 months due to loss od appetite, digestive problems, chewing or
swallowing difficulties?
A 0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake
Weight loss during the last 3 months
0 = weight loss greater than 3kg (6.6 lbs)
B 1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss
Mobility
0 = bed or chair bound
C
1 = able to get out of bed / chair but does not go out
2 = goes out
Has suffered psychological stress or acute disease in the past 3 months?
D
0 = yes 2 = no
Neuropsychological problems
0 = severe dementia or depression
E
1 = mild dementia
2 = no psychological problems
Body Mass Index (BMI) (weight in kg) / (height in m2)
0 = BMI less than 19
F1 1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
IF BMI IS NOT AVAILABLE, REPLACE QUESTION F2. DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.
F2 Calf circumference (CC) in cm
0 = CC less than 31
3 = CC 31 or greater
Screening score
(max. 14 points)
12-14 points:  Normal nutritional status
8-11 points:  At risk of Malnutrition
0-7 points:  Malnourished

ACTIVITIES OF DAILY LIVING AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING ASSESSMENT

Activities of daily living I A D Instrumental activities of daily living I A D
Bathing (sponge and tub shower) Using a telephone
Dressing Traveling
Toileting Shopping
Transferring Preparing meals
Continence Housework
Eating Taking medicine
Managing money
I = INDEPENDENT A = ASSISTED D = DEPENDENT
 THE MINI COG
Word Recall Test Score Interpretation
Word #1
Word #2
Word #3
3 words: Score = 3 Interpretation: non-demented
1-2 words: Score = 1-2 Interpretation will be based on CDT: abnormal = demented; normal = non-demented
0 words: Score = 0 Interpretation: demented

CLOCK DRAWING TEST (CDT)