Relies on medical history and self-report; cognitive and physical performance tests are optional
Multidimensional assessment
Final Score: 0.00
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* Items marked with a star (*) must be completely assessed.
Name
INSTRUCTIONS
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Score : 0
Medical History* (21 items)
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Check any items that the patient has in his/her medical history.
Anemia
Anxiety disorder
Arthritis
Atrial fibrillation/flutter
Cancer within 5 years
Chronic kidney disease
Chronic lung disease
Coronary artery disease
Dementia
Depression
Diabetes
Fall within the past year
Heart failure
Hypertension
Incontinence
Liver disease
Osteoporosis
Peripheral vascular disease
Sensory impairment
Stroke/TIA
Use of >= 5 prescription drugs
Functional Status* (22 items)
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Does the patient need help from another person to perform the following activities (Check all that apply)?
Activities of Daily Living
Feeding
Dressing/undressing
Grooming
Walking (or use of a walker)
Getting in and out of bed
Toileting
Bathing or shower
Instrumental Activities of Daily Living
Using telephone
Using transportation
Shopping
Preparing own meals
Housework
Taking own medications
Managing money
Nagi & Rosow-Breslau Activities
Pulling or pushing a large object
Stooping, crouching or kneeling
Lifting or carrying 10 lbs
Reaching arms above shoulder
Writing or handling small objects
Walking up/dn a flight of stairs
Walking half a mile
Heavy work around house
Performance Tests (4 items)
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Mental State Examination
5 Repeated Chair Stands
Gait Speed
Dominant Handgrip Strength (Select the biological sex)
Nutritional Status (3 items)
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Weight loss > 10 lbs in past year
Body mass index < 21 kg/m²
Serum albumin < 3.5 g/L
Number of positive items: Number of items assessed: CGA-FI (range: 0.0-1.0):
* Items marked with a star (*) must be completely assessed.
HEALTH DASHBOARD
Health Domains
Normal
Low Risk
Moderate Risk
High Risk
Insufficient Data
1. Medical
2. Mobility
3. Muscle Strength
4. ADL disability
5. IADL disability
6. Cognition
7. Nutrition
Frailty Index :
Key references
Jones DM, Song X, Rockwood K. Operationalizing a frailty index from a standardized comprehensive geriatric assessment. J Am Geriatr Soc. 2004 Nov;52(11):1929-33.
Shi SM, McCarthy EP, Mitchell SL, Kim DH. Predicting Mortality and Adverse Outcomes: Comparing the Frailty Index to General Prognostic Indices. J Gen Intern Med. 2020; 35: 1516-1522. doi: 10.1007/s11606-020-05700-w. PMID: 32072368; PMCID: PMC7210351.