<<Miscellaneous:Practice Letterhead>>
Patient’s Name: <<Patient Demographics:Full Name>>					Date of Birth: <<Patient Demographics:DOB>>

FRAIL SCALE RISK ASSESSMENT	SCORE	
F	FATIGUE
In the last four weeks, did you feel tired all or most of the time? 
	
<<In last 4wks, 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 4wks, any difficulty walking up 10 steps?>>	
A	AMBULATION
In the last four weeks, by yourself and not using aids, did you have any difficulty walking 300 metres OR around the block? 
	
<<In last 4wks, any 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 yr, have you lost more than 5kg/5% weight?>>	
SCORE INTERPRETATION:   0 = ROBUST   |   1-2 = PRE-FRAIL   |   ≥ 3 = FRAIL
	<<ADD UP SCORES>>	
RECOMMENDATIONS:

REFERRALS/FOLLOW UP:

	

Date of assessment: 07/12/2018			   		Review date: DD/MM/YYYY

Person completing the assessment: Dr Frederick Findacure