Frailty Survey

Assessor Information
Assessor Name*
First Last
Assessor Email*
Department*
Are You Entering Labs Only?*
Client Information
Client Name*
First Last
If this client does not meet BOTH of the following criteria, please reach out to your supervisor to confirm this client needs a frailty assessment completed and meets the criteria of our grant.*
Please check each box to confirm, as applicable.
- This client is new to this service or has not been an active client with this service for minimally one year
- This client is 60 years or older
Client's Date of Birth*
Month
Day
Year
Client County of Residence*
Client ID*
Assessment Location*
- Home
- Office/Clinic
- Phone
Assessment Completed By*
- Client
- Family Member
- Other
Who was this assessment completed by?*
Assessment Time Interval*
- Initial (In-Person)
- 3-Month (Can Be Phone)
- 6-Month (In-Person)
- 9-Month (Can Be Phone)
- 12-Month
Scale Completed?*
- Yes
- No
Date Scale Completed*
Month
Day
Year
Date Scale Was Due for Completion*
Month
Day
Year
Date Next Scale to Be Completed*
Month
Day
Year
If scale was completed late, please explain:
Reason Scale Was Not Completed
- Client on Hold
- Client Deceased
- Client Discontinued Services
- Unable to Reach Client
- Other
If other, please explain:

Movement
Climbing Stairs*
- No Help
- Some Help (1)
Physical Activity Hours*
- 2+ Hours in 3 Days
- Less than 2 Hours in 3 Days (1)
Fell in Last 90 Days*
- No
- Yes (1)
Dizzy in Last 90 Days*
- No
- Yes (1)
Comments
Please include comments about all items that seem unclear. Use this section to write clarifying comments about your client's status, as well.

Social
Decline in Social Activities in 90 Days?*
- No
- Yes (2)
Reduced Social Activity*
- No
- Yes (1)
Withdrawal from Activities of Interest*
- No
- Yes (1)
Comments
Please include comments about all items that seem unclear. Use this section to write clarifying comments about your client's status, as well.

Nutritional Status (In Last 90 Days)
Weight Loss (Unintentional)*
- No
- Yes (1)
Loss of Appetite*
- No
- Yes (1)
Decrease in Food Eaten (Unintentional)*
- No
- Yes (1)
Comments
Please include comments about all items that seem unclear. Use this section to write clarifying comments about your client's status, as well.

Clinical Data
Diabetes Labs ONLY:
A1C:
Total Cholesterol:
HDL:
LDL:
Triglycerides:
Ratio total/HDL:
Glucose:
Comments
Please include comments about all items that seem unclear. Use this section to write clarifying comments about your client's status, as well.

Frailty Impression Score
1. Very fit – robust, active, energetic, well-motivated and fit; these people commonly exercise regularly and are in the most fit group for their age
2. Well – without active disease, but less fit than people in category 1
3. Well with treated disease – disease symptoms are well controlled compared with those in category 4
4. Apparently vulnerable – although not frankly dependent, these people commonly complain of being “slowed up” or have disease symptoms
5. Mildly frail – with limited dependence on others for instrumental activities of daily living
6. Moderately frail – help is needed with both instrumental and non-instrumental activities of daily living
7. Severely frail – completely dependent on others for activities of daily living, or terminally ill
Please Select Your Frailty Impression Score for This Client*
Comments
Please include comments about all items that seem unclear. Use this section to write clarifying comments about your client's status, as well.

Assessor Information