<PracticeLetterhead>

Patient’s Name: <PtFullName>						Date of Birth: <PtDoB>

FRAIL SCALE RISK ASSESSMENT	SCORE	
F	FATIGUE
In the last four weeks, did you feel tired all or most of the time? 
	
<In last 4 weeks, did you feel tired all or most of time?>	
R	RESISTANCE
In the last four weeks, by yourself and not using aids, did you have any difficulty walking up 10 steps without resting? 
	
<In last 4 weeks, diid you have difficulty walking up 10 steps without rest?>	
A	AMBULATION
In the last four weeks, by yourself and not using aids, did you have any difficulty walking 300 metres (e.g.around the block)? 
	
<In last 4 weeks, did you have difficulty walking 300 metres?>	
I	ILLNESS
Do you have five or more illnesses, such as:
   - Hypertension
   - Diabetes
   - Cancer (not minor skin cancer)
   - Chronic lung disease
   - Have had a heart attack
   - Congestive heart failure
   - Angina
   - Asthma
   - Arthritis
   - Kidney disease
   - Other?	
<Do you have five or more illnesses?>

	
L	LOSS OF WEIGHT
In the past year, have you lost more than 5kg or 5% of your body weight? 
	
<In past year, have you lost more than 5kg or 5% weight?>	
INTEPRETATION OF SCORE:    0 = ROBUST   |    1-2 = PRE-FRAIL    |    ≥ 3 = FRAIL
	<ADD UP SCORES>	
RECOMMENDATIONS:
1. 
	
REFERRALS/FOLLOW UP:
1. 

	

Date of assessment: <TodaysDate>					Review date: DD/MM/YYYY

Person completing the assessment: <UsrName>