Comprehensive Geriatric Assessment
Clinical Frailty Score (Rockwood Scale): ____________
Patient Contact
Home
Care Home
GP
OPD
ED Frailty
Patient's Details
Title: ________________________
Name: ________________________
Date of Birth: ________________________
NHS Number: ________________________
Patient's Address: ____________________________________________________________
GP Practice: ____________________________________________________________
Cognition Emotional
Within Normal Limits Within Normal Limits
Mild Cognitive Impairment Decreased Mood
Dementia Depression
Delirium Anxiety
Abbreviated Mental test (AMT) Score: _____ FAtigue
Mental Capacity Assessment Required Hallucination
Delusion
Main Lifelong Occupation:
Other: ________________________
________________________________________
Motivation Health Attitude
High Excellent
Usual Good
Low Fair
Poor
Couldn't Say
Communication Strength
Speech Within Normal Limits
Within Normal Limits Weak
Impaired Upper
Hearing Proximal
Within Normal Limits Distal
Impaired Distal
Vision Proximal
Within Normal Limits Distal
Impaired
Understanding
Within Normal Limits
Impaired
Exercise
Frequent
Occasional
Not
Baseline (Two Weeks Ago) Current (Today)
Balance Balance
Balance Balance
Within Normal Limits Within Normal Limits
Impaired Impaired
Falls Falls
Falls, Number: ________________ Falls, Number: ________________
Mobility Mobility
Walk Inside Walk Inside
Independent Independent
Slow Slow
Assisted Assisted
Can't Can't
Walk Outside Walk Outside
Independent Independent
Slow Slow
Assisted Assisted
Can't Can't
Transfers Transfers
Independent Independent
Standby Standby
Assisted Assisted
Dependent Dependent
Bed (In/Out) Bed (In/Out)
Independent Independent
Pull Pull
Assisted Assisted
Dependent Dependent
Aid Use Aid Use
None None
Stick Stick
Frame Frame
Chair Chair
Nutrition Nutrition
Weight Weight
Normal Normal
Under Under
Over Over
Obese Obese
Appetite Appetite
Within Normal Limits Within Normal Limits
Fair Fair
Poor Poor
Swallow Swallow
Within Normal Limits Within Normal Limits
Impaired Fluids Impaired Fluids
Impaired Solids Impaired Solids
Elimination Elimination
Bowel Bowel
Continent Continent
Constipated Constipated
Incontinent Incontinent
Bladder Bladder
Continent Continent
Catheter Catheter
Incontinent Incontinent
ADLs ADLs
Feeding Feeding
Independent Independent
Assisted Assisted
Dependent Dependent
Bathing Bathing
Independent Independent
Assisted Assisted
Dependent Dependent
Dressing Dressing
Independent Independent
Assisted Assisted
Dependent Dependent
Toileting Toileting
Independent Independent
Assisted Assisted
Dependent Dependent
IADLs IADLs
Cooking Cooking
Independent Independent
Assisted Assisted
Dependent Dependent
Cleaning Cleaning
Independent Independent
Assisted Assisted
Dependent Dependent
Shopping Shopping
Independent Independent
Assisted Assisted
Dependent Dependent
Medications Medications
Independent Independent
Assisted Assisted
Dependent Dependent
Driving Driving
Independent Independent
Assisted Assisted
Dependent Dependent
Banking Banking
Independent Independent
Assisted Assisted
Dependent Dependent
Sleep
Disrupted
Daytime Drowsiness
Socially Engaged
Frequent
Occasional
Not
Social
Marital Status
Married
Divorced
Widowed
Single
Lives
Alone
Spouse
Other
Home
House, Number of Levels: ________
Steps, Number of Steps: ________
Apartment
Supported Living
Care Home
Other
Supports
Informal
Other
Requires More Support
None
Caregiver Relationship
Spouse
Sibling
Offspring
Other
Caregiver Stress
None
Low
Moderate
High
Caregiver Occupation: _____________________________________
Advance Directive in Place:
Yes
No
CPR Decision:
Allow a natural death
Resuscitate
Assessor: (Name, Grade & Signature):
____________________________________________________________________________
Date: ______________________
Initial Comprehensive Geriatric Assessment Form
Associated Medication *(Mark meds started in hospital with an asterisk) - Consider STOPP / START
Medication Dose Date Commenced
Problem List Action Required Action By
6
7
10
Long Term Conditions
1.
2.
3.
4.
5.
Notes
For MDT discussion, consider long CGA
Long CGA not required, copy of Clinical Frailty score to GP
Outpatient Appointments
Department Date and Time
Assessor: (Name, Grade & Signature):
____________________________________________________________________________
Date: ______________________
