Comprehensive Geriatric Assessment
5
Clinical Frailty Score (Rockwood Scale): ____________
Patient Contact
✔ Home
Care Home
GP
OPD
ED Frailty
Patient's Details
MRS
Title: ________________________
Sarah Smith
Name: ________________________
09.09.1943
Date of Birth: ________________________
/
NHS Number: ________________________
234 home lane, ca
Patient's Address: ____________________________________________________________
Homeward Medical Rooms
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: ________________________
________________________________________
Primary Teacher
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: ________________ ✔ 2
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
Banker
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
Linsinopril 10 mg 12.12.2017
Simvastatin 20 mg 09.02.2018
Asprin 81 mg 09.02.2018
Problem List Action Required Action By
Increase in falls support measures and walking aid use OT
1
Strength assistance with changing and sitting up / out of OT
2 bed
6
7
10
Long Term Conditions
1. high BP
2. high Cholesterol
3. Anxiety
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
Occupational therapy - walking aid asst. 02.09
Nurology 13.09
Assessor: (Name, Grade & Signature):
Frail yet mostly independent. More assistance required.
____________________________________________________________________________
Date: ______________________
