Frailty Patient Review Form
Comprehensive assessment for evaluating patient frailty, functional status, and care needs.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Diagnosis
Relevant Medical History (e.g., chronic conditions)
Current Medications
Functional Status (Activities of Daily Living)
*
Rows
Independent
Needs Assistance
Dependent
Bathing
1
2
3
Dressing
4
5
6
Toileting
7
8
9
Transferring
10
11
12
Feeding
13
14
15
Clinical Frailty Scale Score
*
Please Select
1 - Very Fit
2 - Well
3 - Managing Well
4 - Vulnerable
5 - Mildly Frail
6 - Moderately Frail
7 - Severely Frail
8 - Very Severely Frail
9 - Terminally Ill
Mobility Status
*
Unaided
Uses Walking Aid
Wheelchair Bound
Bedbound
History of Falls in the Past Year
*
No falls
1 fall
2 or more falls
Cognitive Status
*
No impairment
Mild impairment
Moderate impairment
Severe impairment
Nutritional Status
*
Well nourished
At risk of malnutrition
Malnourished
Additional Notes / Recommendations
Reviewer Name
*
First Name
Last Name
Date of Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Reviewer
*
Submit Review
Submit Review
Should be Empty: